- Date
- 3/23/2021
- Report number
- 00132745-AP-104008
- Type
- Abuse: Neglect
- 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. AV is a high fall risk and is care planned for a fall mat, bed alarm, wearing protective padding and frequent checks at least four (4) times per shift. On or about March 23, 2021 AV was found on the floor, resulting in AV reopening a head injury. AV’s bed alarm did not go off, AV’s protective padding was on the floor, and AV had an incontinence episode. Staff only checked on AV two (2) times during the night. The facility failed to follow AV care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP21-03060 $500.00 fine assessed