- Date
- 3/20/2020
- Report number
- 00076803-AP-056638
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned for a two person assist with transfers. On or about March 20, 2020, Alleged Perpetrator 2 (AP2) attempted to transfer AV by him/herself resulting in AV falling. AV was diagnosed with a fracture that required surgical repair. AP2 failed to follow the 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.