- Date
- 1/3/2022
- Report number
- 00177825-AP-141301
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- On or about January 3, 2022, AV experienced a change of condition including stomach pain and weakness. Facility staff were aware of AV’s condition and complaints. As AV’s symptoms persisted, AV requested to go to the hospital. AP3 was on shift when AV made the request to be sent to the hospital. AP3 notified AP2, who was not on shift, of AV’s condition and request according to OAR 411-054-0040(1)(b). AP2 and AP3 agreed to offer AV a remedy. However, AP2 failed to properly assess AV's change of condition, provide sufficient instruction on interventions or monitoring, and failed to follow up on AV’s condition according to OAR 411-054-0045(1)(f). AP3 failed to create a temporary service plan for interventions or monitoring after administering a medical remedy according to 411-054-0036(2)(e). Additionally, AV was not sent to the hospital upon AV’s request. AV continued to experience symptoms related to the change of condition, and passed away overnight. Respondent failed to oversee facility staff and ensure that staff followed the applicable regulations and provided appropriate care. Failure to assess, care plan and follow-up on treatment related to AV's change of condition, and failure to honor AV’s request to go to the hospital, constituted a failure to provide basic care and services as required by rule, resulting in a risk of serious harm to the resident. The failure constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- ALFCP23-00406 $1125.00 fine assessed