- Date
- 11/7/2019
- Report number
- 00059399-AP-042250
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) requires staff assistance with transfers and is care planned for two staff to assist with the use of a gait belt. On or about November 7, 2019, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) assisted AV with a transfer and did not use a gait belt. During the transfer AV fell sustaining a fractured leg. AP3 admitted to making the decision to not use a gait belt during the transfer. AP2 and AP3 did not follow AV's care plan which is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed which is a violation of Oregon Administrative Rules.