Violation Details: 00231378-AP-189273

Records Request Print
Date
11/11/2022
Report number
00231378-AP-189273
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
On or about November 11, 2023, staff found the Alleged Victim (AV) on the floor of his/her room, with his/her head bleeding. The injuries appeared that AV had been on the ground for some time. AV is care planned to be checked every two hours during night shift. Alleged Perpetrator #2 (AP2) was working the morning of this fall. AP2 was to check AV every two to three hours. AP2 had stated that they had checked on AV at 5:00 am, however, later admitted that they did not. The last known check on AV was at 3:40 am. AV was found at approximately 6:00 am by morning shift staff. It is unknown how long AV was on the ground. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.