- Date
- 4/10/2022
- Report number
- 00194054-AP-155288
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned to have gait belt assistance with all transfers and wear non-skid footwear when transferring. On or about April 10, 2022, Alleged Perpetrator #2 was transferring AV from bed to wheelchair when AV experienced a fall hitting h/h head resulting in a bump on the back of AV head, and AV experienced chest pain. AV was transported to emergency room. 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.