- Date
- 2/1/2022
- Report number
- 00183169-AP-145756
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- On or about February 1, 2022, Alleged Preparator 2 (AP2) failed to prioritize the assessment of the Alleged Victim (AV), who had a documented serious cardiac medical condition. At time of incident, AV presented with acute symptoms, including significant shortness of breath, which required immediate clinical attention by AP2. According to facility documentation and staff interviews, AP2 did not assess AV despite the presence of symptoms indicating a potential medical emergency. Approximately one hour later, AV was evaluated by Witness 2 (W2), who determined that AV’s oxygen saturation levels were critically low. Due to the worsening of AV’s condition, W2 arranged for AV to be transferred to the hospital, where AV required a three-day inpatient stay for treatment of exacerbated shortness of breath. AP2’s delay in assessment placed AV at increased risk, given AV’s underlying cardiac condition and low oxygen levels. AP2 failed to check on AV after being notified that AV required a nursing assessment for shortness of breath. This failure resulted in AV waiting at least one hour in respiratory distress due to lack of oxygen. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the quality of services provided, as well as for the supervision, training, and conduct of staff. The facility failed to ensure AV received appropriate nursing services is a violation of Oregon Administrative Rules.