Violation Details: 00288796-AP-243051

Records Request Print
Date
10/3/2023
Report number
00288796-AP-243051
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0030(1)(e)(A) and (H)
External site: 411-054-0036(2)(g)
Findings
The facility failed to provide fall prevention/interventions resulting in Alleged Victim (AV) sustaining multiple falls. Based on facility documentation and interviews, between June 29, 2023, and October 8, 2023, AV fell a total of 20 times transferring himself/herself in his/her room. Facility records noted the only fall prevention interventions made during this time period was to check on AV and remind him/her to use the call light for assistance with transfers. It was documented on February 22, 2022, that AV does not have the cognitive ability to understand the need to call for assistance. AV had no documented injuries or pain related to any falls during this time period. The facility's failure to properly care for AV's care needs is a violation of Oregon Administrative Rules.