- Date
- 10/20/2023
- Report number
- 00292879-AP-246739
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On October 20, 2023, Alleged Perpetrator 2 (AP2), assisted Alleged Victim (AV) from AV's bed to AV's recliner chair. AP2 was unable to complete the transfer so AV was lowered to the floor and AV's ankle twisted on the way down. AV agreed to go to the hospital on October 24, 2023, for treatment after experiencing ongoing pain and discomfort. AV was diagnosed with a fracture of AV's left foot. Based on facility documentation and interviews, AV is a two-person transfer and AP2 understood the requirement; however, assisted AV independently. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.