- Date
- 9/22/2021
- Report number
- 00161930-AP-128393
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for assistance with transfers and the use of a gait belt during transfer. On or about September 22, 2021, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and allowed AV to self-transfer without the use of a gait belt resulting in a non-injury fall. AP's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.