- Date
- 4/27/2024
- Report number
- 00327657-AP-279049
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfers. On or about April 27, 2024, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV by themselves resulting in AV receiving a skin tear requiring first aid and a hospital visit. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.