Violation Details: 00064341-AP-046313

Records Request Print
Date
12/26/2019
Report number
00064341-AP-046313
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate 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)(r)
Findings
The Alleged Victim (AV) was care planned to have a tab alarm attached to his/her wheelchair. On or about December 26, 2019, Alleged Perpetrator 2 (AP2) failed to attach the AV's tab alarm after he/she performed a transfer to the AV's wheelchair. The AV tried to self-transfer and fell to the floor, resulting in pain, swelling and discoloration to the right side of his/her head. AP2's actions caused unreasonable discomfort to AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.