- Date
- 9/26/2023
- Report number
- 00287949-AP-242094
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have balance support when walking. Use of gait belt for transfers and when walking with AV. On or about September 26, 2023, Alleged Perpetrator #2(AP2) was assisting AV to ambulate and was not holding onto the gait belt to ensure AV's safety. AV fell and sustained a fracture to his/her left leg, and will have hip surgery . 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.