- Date
- 1/18/2020
- Report number
- 00067583-AP-048962
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to documentation, Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim's (AV) care plan to check in with him/her prior to each meal as AV is a fall risk. The failure resulted in AV experiencing an unwitnessed fall, was not checked on for at least four hours and was transported to the hospital with a head injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect AV from neglect which is a violation of Oregon Administrative Rules.