Violation Details: 00316143-AP-268318

Records Request Print
Date
2/27/2024
Report number
00316143-AP-268318
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: 411-054-002(2)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0036(2)(g)
Findings
Alleged Victim’s (AV’s) service plan states he/she is a two-person transfer with a gait belt. On or about February 17, 2024, Alleged Perpetrator 2 (AP2) provided AV with a one-person transfer from AV’s recliner to AV’s wheelchair. AV became weak during the transfer, fell and fracture AV’s hip. AP2 failed to follow AV’s care plan around two-person transfer, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was being followed, which is a violation of Oregon Administrative Rules.