- Date
- 7/22/2023
- Report number
- 00275704-AP-230309
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care and is care planned to have two people assist with incontinence care. On or about July 22, 2023, AV was found in a decayed incontinence brief lying on a urine soaked mattress. According to an investigation, the Alleged Perpetrator #2 (AP2) did not call float staff to assist the AV with incontinence care and left AV in a wet bed shivering, resulting in a loss of personal dignity and unreasonable discomfort. 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.