- Date
- 3/19/2024
- Report number
- 00320227-AP-272077
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 3 (AP3) failed to follow the care plan to ensure the bed was lowered completely before transferring the Alleged Victim (AV) causing a fall with injury. On or about March 19, 2024, Alleged Perpetrator 2 (AP2) and AP3 were transferring the AV using the slide board transfer technique. Both AP2 and AP3 were trained to safely perform this transfer technique. AP3, who was closer to the head of the bed was responsible for ensuring the bed was lowered to the lowest setting before attempting the transfer. AP3 did not ensure the bed was lowered before performing the transfer. During the transfer, the AV fell and sustained a fractured toe and a back injury. The failure to follow the care plan for safe transfer technique resulted in a fractured toe and back pain, 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.