- Date
- 7/16/2021
- Report number
- 00150437-AP-119043
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned to have frequent checks at night. On or about July 16, 2021, AV had an unwitnessed fall that caused a broken nose. At around 3:15 am, AV left his/her room and was not found until 5:30 am. Alleged Perpetrator 2 (AP2) was sitting in the kitchen when AV walked out of his/her room and did not do safety checks as required. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was been followed, which is a violation of Oregon Administrative Rules.