Violation Details: 00085303-AP-063695

Records Request Print
Date
5/20/2020
Report number
00085303-AP-063695
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious 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)(f) and (r)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) was care planned to have a two-person assist with gait belt for all transfers. On or about May 20, 2020, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were providing AV transfer assistance without the use of a gait belt. AV was stood up by AP2 and AP3, AV lost his/her balance and fell forward which resulted in AV hitting his/her head and sustaining a laceration requiring sutures. AP2 and AP3 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.