Violation Details: 00189157-AP-150955

Date
3/13/2022
Report number
00189157-AP-150955
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 March 12, 2022, at about 10:30pm, AV lost his/her balance trying to change AV.s incontinence brief. AV lowered AV’s self to the floor and was on their knees leaning against AV’s bed. AV was then unable to get up. At an unknown time between 5:30 and 6:00 am the next day, Alleged Perpetrator 2 (AP2) entered AV’s room to administer medication. AP2 found AV on their knees, leaning against their bed. AP2 did not assist AV off the floor and simply placed AV’s medication in their mouth and poured water in AV’s mouth. AP2 did not notify staff that AV was on the ground. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV has a safe environment, which is a violation of Oregon Administrative Rules.