Violation Details: 00104166-AP-079450

Records Request Print
Date
9/23/2020
Report number
00104166-AP-079450
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) is care planned to be checked on twice per shift, every shift. On or about the night of September 23, 2020 to the morning of September 24, 2020, Alleged Perpetrator 2 (AP2) was responsible for checking on AV. AP2 logged and made statements indicating that he/she had checked on AV as outlined the care plan. AV was found in the morning of September 24, 2020, by care staff stuck in his/her electric ambulatory device due to the device battering dying. AV was unable to make it to the restroom and had to void their bowels on themselves and was stuck in his/her device all night. AP2 failed to follow AV's care plan which is 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.