- Date
- 3/19/2024
- Report number
- 00319985-AP-271829
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about March 19, 2024, Alleged Perpetrator 2 (AP2) assisted Alleged Victim (AV) in taking off his/her diabetic socks. AP2 failed to put AV's grip socks on and failed to walk AV to his/her bed according to AV's care plan when AV's diabetic socks are removed. As a result of AP2 failing to follow AV's care plan, AV experienced a fall that resulted in AV hitting the back left side of his/her head on the floor, causing a large, cantaloupe sized hematoma. AP2's actions caused AV unreasonable discomfort which is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.