Violation Details: 00162342-AP-128815

Records Request Print

Date: 9/26/2021
Report number: 00162342-AP-128815
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: 411-054-0028(2)
Findings: The Alleged Victim (AV) was known to exhibit extreme agitation and physical aggressiveness and had a behavior support plan in place to de-escalate AV's behaviors. On or about September 26, 2021, AV was exhibiting high agitation. Alleged Perpetrator #2 (AP2) attempted redirection which was not successful. AP2 was asked to discontinue the interaction with AV and give him/her some space, which is what the behavioral plan dictates. AP2 instead threw ice water over AV's head to stop his/her aggression, causing unreasonable discomfort to AV. AP2 failed to follow the behavioral plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.