Violation Details: 00300161-AP-253510

Records Request Print
Date
11/21/2023
Report number
00300161-AP-253510
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
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
The Alleged Victim (AV) was walking with the assistance of a staff member and had a fall in the hallway on or about November 21, 2023. AV walks with one hand on his/her walker and one on the handrail. Staff walking with AV tried to redirect AV from doing this action but was unsuccessful. While AV was walking and grabbing the hand rail, he/she leaned on the hand rail and lost his/her balance, and when AV reached for the handrail again, he/she was at a door and there was no handrail, and AV slid to the floor against the wall. AV suffered a broken femur in this process. Facility staff tried to redirect AV but were unsuccessful. There is no evidence that the facility could have foreseen or prevented this particular fall. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.