Violation Details: 00139486-AP-109780

Records Request Print
Date
5/1/2021
Report number
00139486-AP-109780
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for his/her care. On or about May 1, 201, AV pressed his/her call light and when staff did not respond, AV self-transferred. AV tripped on his/her nighttime catheter bag and fell out of bed and as a result, AV’s ankle was swollen. On this day, Alleged Perpetrator 2 (AP2), did not followed the service plan because AV’s nighttime bag was not changed/replaced with his/her daytime catheter bag. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which if a violation of Oregon Administrative Rules.