Violation Details: 00261920-AP-217039

Records Request Print
Date
3/25/2023
Report number
00261920-AP-217039
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim (AV) is care plan to be a 2-person transfer. On or about March 25, 2023, Alleged Perpetrator 2 (AP2) tried to put AV to bed but was rushing and claiming he/she could do it by him/herself. AP2 did not know how to do a proper transfer and would not listen to facility staff. As a result, AV was screaming in pain, and suffered two skin tears in the process. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.