- Date
- 4/24/2024
- Report number
- 00327540-AP-278911
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to assist with transfer
- Result
- Substantiated
- Findings
- Alleged Victim Service Plan indicates AV requires use of a wheelchair for mobility. AV is non-ambulatory. AV will need one person assist with transfers. Unlicensed assistive personnel to physically assist AV through transfer. AV is a high risk of falls due to poor safety awareness, cognitive deficiencies and being on diuretic. On or about April 24, 2024, Alleged Perpetrator 2 (AP2) AP2 checked on AV and noticed AV was soaked in urine. AP2 went to assist AV into wheelchair and grabbed AV by AV's hands and pulled AV up, resulting in a skin pulling away from left hand. AV is slow to move and requires staff to be in front of AV to guide transfers. Staff are to use under the arm technique for transfer or gait belt as needed. Care Partner Training and Competency Check List has Transferring and Gait Belts listed as part of training requirements. AP2 initialed section as acknowledging completion of training, dated April 26, 2022, Pre-Service Dementia Care Training for Direct Care Staff completed on February 23, 2024, by AP2. Updated Care Partner Description with list of responsibilities and requirements signed on March 21, 2024, by AP2. AP2 knew that there was a gait belt in facility or could have called for a second staff but felt AP2 could lift AV on own without assistance or assistive devices. AP2 failed to assist a resident transfer from one place to another using generally accepted techniques, and provide a safe environment when transferring, the facility failed to provide a safe environment when resident is transferring, which is a violation of Oregon Administrative Rules.