Violation Details: 00130208-AP-101690

Records Request Print
Date
3/18/2021
Report number
00130208-AP-101690
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
On or about March 18, 2021, the Alleged Perpetrator #2 (AP2) failed to follow the care plan by attempting to transfer the Alleged Victim (AV) by him/herself when AV is care planned as a two person transfer. AV suffered a fall, resulting in a goose egg and bruise to his/her head, and being sent out to the hospital for evaluation. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.