- Date
- 3/25/2024
- Report number
- 00322275-AP-274145
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On March 25, 2024, Alleged Victim (AV) was out of the facility on a shopping trip with Alleged Perpetrator 2 (AP2). While AV was transferring to the facility's bus from wheelchair, AV became weak and fell. Based on facility documentation and interviews, at time of incident, AV was using a store provided motorized wheelchair and AV's wheelchair was already inside the bus. AV stood unassisted on the ramp to transfer into the bus. AV became weak and AV could not get to AV's wheelchair which was already located on the bus resulting in AV falling. During transfer, AV experienced increased pain to his/her feet, needing to take a few steps towards AV's wheelchair but AV could not pick his/her feet up and AV's legs buckled, causing AV to fall. AV's pain level was rated from one to ten, with AV stating his/her pain was at a ten. During transfer from store provided motorized wheelchair to the AV's wheelchair already located inside the facility's bus, AP2 failed to provide the basic care and services necessary for the safety of AV, which resulted in AV falling, injuring his/her side and head. AP2 received training specifically surrounding transferring residents, securing wheelchairs, securing residents on the lift, ambulation, and knowing the resident's ambulatory needs. AP2 stated in his/her interview that where AV's wheelchair was located was "poorly thought out on my part". AP2's actions is considered neglect of care which constitutes abuse. The facility failed to ensure a safe environment for AV which is a violation of Oregon Administrative Rules.