Violation Details: 00142876-AP-112653

Records Request Print
Date
6/2/2021
Report number
00142876-AP-112653
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
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) is a known fall risk. Between March 15, 2021 and June 02, 2021 AV experienced eight (8) falls resulting in two head injuries, fractured nasal bone, lacerations to the face, a brain bleed, bruising and pain. The facility failed to put effective, person-centered interventions in place after repeated falls, leading to multiple falls with injuries, which is a violation of residents rights is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP21-02896 $1125.00 fine assessed