- Date
- 1/22/2020
- Report number
- 00127706-AP-099499
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to use restraint properly
- Result
- Substantiated
- Findings
- Alleged Victim (AV) ambulates in his/her wheelchair using his/her feet and enjoyed ambulating through the facility. AV has a history of falling out of his/her wheelchair due to leaning forward. Alleged Perpetrator 2 (AP2) determined AV should use a tilting wheelchair to prevent AV from falling. AV’s feet could not touch the ground when in the tilting wheelchair. AP2 directed staff to have AV use the tilting wheelchair for an unspecified period of time, but at least from January 22, 2021 through February 2, 2021, before AP2 had completed an assessment on the use of a device with restraining qualities. On or about January 22, 2021, AV expressed that he/she did not like the tilt wheelchair. AP2’s assessment did not include all of the necessary elements to approve a devise with restraining qualities. AP2’s actions are considered a wrongful use of a restraint as defined in OAR 411-020-0002(1)(h)(A)(i) and constitutes abuse. The facility failed to provide oversight and monitoring of AP2 and facility staff actions and failed to care plan and implement appropriate interventions to mitigate AV’s risk of injury due to falls, which is a violation of resident rights, is neglect of care as defined in OAR 411-020-0002(1)(b)(A)(i) and constitutes abuse.
- Sanction
- RCFCP21-03130 $1500.00 fine assessed