- Date
- 9/1/2020
- Report number
- 00102328-AP-077858
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about March 21, 2021, the Department received a petition for reconsideration. On or about May 19, 2021, the Department granted the petition. The following narrative is based on evidence in the original adult protective services investigation and additional investigative actions as outlined in Reconsideration 00102328.
On or about September 1, 2020, at approximately 6:01 am, Alleged Victim (AV) fell first on his/her knees with the rest of AV's body following, coming to a rest on the floor. AV began bleeding from a wound on his/her forehead. AV's feet moved in a seizure-like pattern after the fall, and AV never appeared to regained consciousness. AV was breathing, making small noises from his/her mouth and had a heartbeat at the time of the fall. Staff attended to AV. The facility called emergency services at 6:30 am and facility staff attempted to perform CPR. Emergency services arrived and AV was pronounced deceased at approximately 6:39 am. A review of the facility change of condition related to falls does not direct staff to call emergency services during a medical emergency. A review of AV's POLST revealed that he/she wanted comfort measures only (Allow Natural Death) and has a do not resuscitate order. The facility failed to follow AV's POLST by providing CPR and the facility failed to respond to a medical emergency appropriately which is a violation of resident rights, is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(B).
- Sanction
- RCFCP21-02755 $1500.00 fine assessed