- Date
- 8/1/2023
- Report number
- 00278348-AP-232992D
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to use restraint properly
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.