- Date
- 1/26/2024
- Report number
- 00318165-AP-270192
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is care planned to have footrest down on recliner in AVs room. AV MAR indicates *Elevate AV’s legs for one hour in h/h bed or common area recliner (NOT the recliner in h/h room!) for 1 hour after meals for edema. On or about January 26, 2024, Alleged Perpetrator #2(AP2) AV was found on the floor by the recliner by h/h bed and the foot of the recliner was up. AV was getting up from the recliner, fell and hit h/h head. AV was sent to the ER. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.