Violation Details: 00298674-AP-252110

Records Request Print
Date
11/19/2023
Report number
00298674-AP-252110
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)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
On or about November 19, 2023, the Alleged Victim (AV) fell backwards, hit his/her head and back on his/her television stand, causing a rib fracture and a punctured lung. AV was care planned to be transferred with a gait belt. Alleged Perpetrator #2 (AP2) was walking AV back to his/her room and was going to transfer AV to his/her bed, turned his/her back to AV to straighten AV's bed and AV fell. AP2 failed to follow the care plan by not using a gait belt. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.