Violation Details: 00261619-AP-216728

Records Request Print
Date
5/1/2023
Report number
00261619-AP-216728
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)(a)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV is care planned for two (2) person assistance with gait belt for all transferring. On or about May 01, 2023, Alleged Perpetrator #2 (AP2) was transferring AV from a wheelchair to a bed when h/h ankle got caught in the wheelchair causing a skin tear. 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.