Violation Details: 00246226-AP-202395

Records Request Print
Date
2/4/2023
Report number
00246226-AP-202395
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for h/h care. AV is care planned for a two-person assist transfer to toilet. On or about February 04, 202, Alleged Perpetrator #2 (AP2) attempted to transfer AV alone, when AV experienced a muscle spasm in h/h leg. AP2 lowered AV to the floor in an "assisted fall" while AV was experiencing a bowel movement, causing AV unreasonable discomfort and loss of dignity. 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.