Violation Details: 00273230-AP-227982

Records Request Print

Date: 7/8/2023
Report number: 00273230-AP-227982
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: 411-054-0036(2)(g)
Findings: The Alleged Perpetrator 2 failed to follow the Alleged Victim's (AV) care plan to ensure h/h pressure alarm was in place to alert staff to AV's attempts to transfer. The failure resulted in AV experiencing an unwitnessed fall and AP2's actions are considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.