Violation Details: 00166608-AP-132111

Records Request Print
Date
10/22/2021
Report number
00166608-AP-132111
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV requires a two person assist with Hoyer lift for transfers. On or about October 22, 2021 Alleged Perpetrator #2 (AP2) used the Hoyer lift to transfer AV from Bed to wheelchair. AP2 placed the Hoyer sling under AV incorrectly, so when AV was placed onto his/her wheelchair he/she slid down toward to the floor. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.