- Date
- 5/20/2021
- Report number
- 00140997-AP-111068
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is serviced planned for a stand by assist for transfer and toileting. On or about May 20, 2021 AV had gotten up from the dinner room to use the restroom Alleged Perpetrator 2 (AP2) came to assist AV, but had left the water running in the kitchen and went back to turn the water off. AV continued walking to the bathroom. AP2 returned to assist AV and found AV on the floor in the bathroom. AV was transported to the hospital diagnosed with a broken femur that required surgical repair. AP2 failed to follow AV's care plan which is considered neglect of care and is abuse as defined in OAR 411-020-0002(1)(b)(A)(i). the facility failed to ensure that AV's care plan was followed which is a violation of Oregon Administrative Rules.