- Date
- 7/21/2021
- Report number
- 00151162-AP-119635
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Perpetrator 2 (AP2) failed to follow Alleged Victim's (AV) care plan which resulted in AV falling in his/her bathroom sustaining a head injury and was sent to the hospital for treatment. An investigation determined that AP2 forgot to turn on AV's sensor pad to alert staff when AV attempts to self transfer. AP2's action is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.