Violation Details: 00167634-AP-132961

Records Request Print Provider Details
Date
10/27/2021
Report number
00167634-AP-132961
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to answer call light in a timely manner
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(a)(f) and (r)
411-054-0028(2)
411-054-0030(1)(e)
411-054-0070(1)
Findings
The Alleged Victim (AV) has a history of falls and is service planned to be checked every two hours and has a sensor on his/her bed that alerts staff when AV is out of bed. On or about October 27, 2021, the sensor shows AV was out of bed at approximately 9:11pm, and the call system showed eighty-six (86) pages from AVs room. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #4 (AP4) never responded to any of these pages to check on AV. At approximately 12:23 AM, AV was heard yelling from his/her room, staff checked on AV and found AV on the floor from a fall. AV was not harmed in the fall, however, AV was placed at risk for harm. AP2 and AP4 failed to answer the call light in a timely manner, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator #3 (AP3) was working the assisted living side of the building the night of the incident, therefore abuse against AP3 was found to be inconclusive. The facility failed to ensure AVs needs were met which is a violation of Oregon Administrative rules.