Violation Details: 00083633-AP-062307

Date
5/13/2020
Report number
00083633-AP-062307
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Findings
Alleged Victim (AV) is care planned to be checked on for toileting needs and fall risk every two hours during night shift. On or about May 13, 2020, at around 6:00 am during rounds, staff found AV on the floor with blood all over the floor and bathroom from AV's head and Face. AV was transported the hospital and diagnosed with a nose fracture and multiple abrasions to his/her face. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were responsible for checking on AV and both admitted to not completing the task. AP2 and AP3 failed to follow AV's care plan which is considered neglect of care and is abuse. The facility failed to ensure AV's care plan was followed which is a violation of Oregon Administrative Rules.