- Date
- 10/20/2023
- Report number
- 00292096-AP-246081
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) Service Plan, dated August 30, 2023, AV can understand and be understood and is occasionally disoriented to time. AV can make simple decisions, Mobility: AV is able to walk independently with walker, staff are to ensure walker is always within reach. Fall Prevention: AV has Incontinence and Balance Issues. Staff will follow a routine toilet schedule - before/after each meal, and including beginning, middle and end of shift. Toileting: AV is incontinent of bowel and bladder and needs assistance when toileting, most of the time, AV can change themself and use the restroom independently, however there may be days (very rarely) where staff will need to provide hands on assistance to AV. On or about October 20, 2023, AV stated that s/he pulled h/h call light for toileting assistance and was left waiting for an hour. The call light report does not reflect any call lights on October 20, 2023, and 1 call light of about 5 minutes on October 19, 2023. The call light system does not work in a reliable manner reported by facility staff. It is unclear if AV only used the call light once during the two-day period, or if the call light system is not recording entries properly. AV’s care plan contradicts itself when it states that AV is incontinent and needs assistance toileting and that AV only very rarely needs hands on assistance for toileting and AV’s service plan does not provide instructions to staff on how to provide care for AV when s/he has diarrhea and needs increased assistance, which is a violation of Oregon Administrative Rules.