- Date
- 12/16/2020
- Report number
- 00117283-AP-090745
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. Documentation and interviews provided to the department indicate AV is care planed as a two-person total assist for toileting and is NOT to be bed roll changed in bed, AV is to have brief changes every two (2) hours as per Cascade Living policy, and TSP/alert dated on or about December 17, 2020, indicates alert in place to turn every 2 hours. On or about December 16 & 17 2020, Alleged Perpetrator #2 (AP2) was the only person working the Noc shift in the COVID unit from 6:00pm to 6:00am. The allegation that AP2 failed to follow the care plan was investigated and the determination was not substantiated. The facility failed to ensure there was adequate staffing and the care plan was being followed, which is a violation of Oregon Administrative Rules.