- Date
- 7/29/2023
- Report number
- 00276918-AP-231717
- 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 transfer. AV is also not to be left alone while he/she is toileting. On or about July 29, 2023, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan. AP2 transferred AV by themselves and left AV alone on the toilet. AV attempted to get off the toilet by him/herself, which resulted in AV falling and hitting his/her head. AV experienced head pain and dizziness. 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.