- Date
- 9/17/2021
- Report number
- 00162637-AP-128929
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. On or about September 17, 2021, Alleged Perpetrator 2 (AP2) was assisting AV to transfer from his/her wheelchair into his/her bed. AP2 rushed the transfer and moved faster than AV preferred. There was another staff member who was unable to assist during the transfer because AP2 thought he/she could do the transfer on his/her own though AV is a two-person transfer. AP2 grabbed the back of AV’s pants to assist AV with the transfer but AV slid from his/her bed. AV and Ap2’s legs hit during the transfer causing AV to have pain that subsided 10 minutes following the fall. AV got scared during the rushed transfer. AP2 failed to provide a safe for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV, which is a violation of Oregon Administrative Rules.