- Date
- 12/16/2020
- Report number
- 00117287-AP-090749
- 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 for staff to remind AV to use the toilet every 2 hours, AV can wipe h/herself, but needs reminders and escort to the restroom. TSP dated on or about December 17, 2020, indicates every 2 hour turns to offload pressure on buttocks, related to AV having redness on h/h buttocks. 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. AV had on the marked day shift briefs at the end of AP2's 12-hour shift both mornings, AV also had not been repositioned, resulting in unreasonable discomfort to AV. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.