Violation Details: 00233491-AP-191161

Records Request Print
Date
11/18/2022
Report number
00233491-AP-191161
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide oversight and monitoring of change of condition
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: 411-054-0045(1)(f)(A)
Findings
On or about November 18, 2022, the Alleged Victim (AV) slipped out of his/her recliner and was found on the floor. Alleged Perpetrator #2 (AP2) saw AV, however, did not perform an assessment on AV for injuries. On November 26, 2022, AV was assessed for injury after a fall, and staff found that AV had latent discoloring on his/her lower back and was expressing pain. AV was sent to the hospital and was diagnosed with a hematoma to the abdomen and abnormal lab ranges. AP2's failure to complete an assessment on AV 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.