- Date
- 6/9/2023
- Report number
- 00274467-AP-229115
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfers. On or about June 9, 2023, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV by themselves resulting in AV experiencing unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.