- Date
- 1/5/2021
- Report number
- 00119097-AP-092358
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care plan to have staff members ensure AV is wearing appropriate footwear. On or about January 5, 2021, AV had a witness fall which resulted in AV hitting his/her head on the wall and hand railing. AV was witnessed to have been wearing his/her roommate’s shoes at the time of the fall, which are too big for AV. Alleged Perpetrator 2 (AP2) had been the care staff that had assisted AV with putting on his/her shoes. 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.