Violation Details: 00060879-AP-043699

Records Request Print
Date
11/30/2019
Report number
00060879-AP-043699
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(r)
Findings
Alleged Victim (AV) is care planned to have his/her catheter flushed twice per day, once in the morning and once in the evening. AV’s care plan states to immediately contact Hospice for any concerns. On or about November 30, 2019, Alleged Perpetrator 2 (AP2) encountered difficulty with AV’s catheter flush in the morning and was unable to complete the flush. AP2 did not contact Hospice but logged AV’s flush as completed in the MAR and waited to inform the oncoming staff approximately three hours later. AV did not experience harm or discomfort but was placed at risk of harm by infection by not having the catheter flushed until evening. AP2's actions are considered neglect of care and constitute abuse. The facility failed to ensure that AV’s care plan was followed which is a violation of Oregon Administrative Rules.