- Date
- 5/21/2022
- Report number
- 00201554-AP-162219
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfers. On or about May 21, 2022, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV by themselves, causing AV to slide to the floor, which resulted in AV experiencing unreasonable discomfort and bruises. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.