Violation Details: 00294144-AP-247933

Records Request Print
Date
10/23/2023
Report number
00294144-AP-247933
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(r)
Findings
According to the documentation, the Alleged Perpetrator 2 (AP2) and the Alleged Perpetrator 3 (AP3) failed to follow the care plan for the Alleged Victim (AV) when a Temporary Service Plan (TSP) was implemented on or about September 20, 2023, to use a mechanical life for the AV. The failure resulted in the AP2 and AP3 transferring the AV by use of a gait belt and pivot transfer causing a skin tear on the AV’s shin, which is a violation of resident rights and is considered abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.