Violation Details: 00104670-AP-079854

Records Request Print
Date
9/27/2020
Report number
00104670-AP-079854
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0027(1)(r)
External site: 411-054-0300(4)(i)
Findings
The facility failed to provide safe environment for the Alleged Victim (AV). On or about September 27, 2020, AV was smoking in his/her room and caught him/herself on fire. The smoke detector and/or the sprinkler system did not activate to alert staff. AV suffered burns to his/her body and later passed at the hospital due to burns from the event. An investigation determined no facility abuse occurred, however the facility did fail to provide a safe environment by not ensuring the fire alarm was set to alert staff to a fire, which is a violation of Oregon Administrative Rules.