Violation Details: 00145064-AP-114643

Records Request Print
Date
6/10/2021
Report number
00145064-AP-114643
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: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings
The facility failed to update the Alleged Victim's (AV) service plan for interventions to reduce the risk of falls after AV suffered two falls within two days due to weakness. AV suffered a third fall on June 8th still without documentation of any interventions. On June 10th, AV fell again while staff were trying to transfer him/her to a wheelchair, resulting in a cut to his/her finger and a fractured pelvis. The facility's failure is a violation of Oregon Administrative Rules.