- Date
- 1/2/2020
- Report number
- 00118943-AP-092223
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned to only receive personal care from same gender staff. On or about January 2, 2021, Alleged Perpetrator 2 (AP2), who is the opposite gender to AV, provided AV with incontinence care while AV was in bed. AV grabbed AP2’s sweatshirt pocket and would not let go, AP2 grabbed AV’s arm to pull AV off. AV's arms slipped and AP2’s hands caused AV to sustain a skin tear to his/her forearm. The incident report stated that the skin tear looked like the top layer of AV’s skin just peeled right off. A same gender staff was working during that shift but was not asked to provide personal care. AP2 failed to follow AV’s care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.