- Date
- 1/4/2024
- Report number
- 00311569-AP-264081
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to the documentation, on or about February 02, 2024, the Alleged Perpetrator 2 and 3 (AP2) and (AP3) laid the Alleged Victim (AV) in bed at approximately 1400 and did not follow the care plan to put the AV’s fall mat in place. Alleged Perpetrator 4 (AP4) conducted a safety check at approximately 1600 and noticed the fall mat was not in place but did not put it in place. At approximately 1740, the AV was heard screaming and the AP2 found the AV on the floor and sustained bruising and experienced unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.