- Date
- 3/31/2023
- Report number
- 00255933-AP-211417
- 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 plan for staff to do safety checks on AV 48Xs per day(or 30 minutes safety checks), AV is a high fall risk. On or about March 30, 2023, Alleged Perpetrator 2 (AP2) was scheduled to work NOC shift from 10pm to 6:30am the next morning. AP2 went home at 3am on March 31, 2023, and had not done toilet or safety checks on AV. AV was found soaked in urine by another staff member after AP2 had left. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.