Violation Details: 00311944-AP-264449

Records Request Print
Date
2/7/2024
Report number
00311944-AP-264449
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide inservice
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about February 7, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she attempted to use a hoyer lift to transfer AV without another person to assist, resulting in AV having a fall with fractured tibia/fibula. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment, which violates Oregon Administrative Rules.