Violation Details: 00257936-AP-213254

Records Request Print
Date
4/14/2023
Report number
00257936-AP-213254
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
Findings
The Alleged Perpetrator 2 failed to follow the Alleged Victim's (AV) care plan to ensure s/he does not receive plastic silverware with meals due to a history of chewing and ingesting them. On or about April 14, 2023, AP2 gave AV breakfast with a plastic spoon, which was later discovered be partially missing causing AV to be transferred to the hospital for assessment. AP2's failure placed AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to assure AV's safety, which is a violation of Oregon Administrative Rules.