Violation Details: 00059566-AP-042388

Records Request Print
Date
11/20/2019
Report number
00059566-AP-042388
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) is a known fall risk and requires supervision when in the common areas. On or about November 20, 2019, Alleged Perpetrator 2 (AP2) reportedly left the common area unattended. In AP2's absence AV ambulated without assistance and fell resulting in a fractured clavicle. After further investigation, due to the filing of a Petition for Reconsideration, the allegation that AP2 failed to provide a safe environment was unable to be determined. The facility failed to ensure a qualified caregiver was present which is a violation of Oregon Administrative Rules.