- Date
- 4/18/2024
- Report number
- 00328877-AP-280554
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) has a history of falls and was showing signs of nearing end of life by being restless and not sleeping well at night. Alleged Perpetrator 2 (AP2) worked at this facility before and has access to resident records. Witness 4 (W4) informed AP2, AV was a fall risk and needed to be watched with stand by assist for transfer and ambulation. On or about April 19, 2024 AV had an unwitnessed injury fall in the living room. AP2 claimed to be in the bathroom when fall occurred, but was reportedly seen on camera in the living room when the fall happened. AV and AP2 were reported as only persons in the room at the time and AP2 was seated in a row of chairs behind AV. AV was seen rocking back and forth trying to get up from the chair before falling with AP2 still seated behind AV in the living room not looking in AV's direction. AP2 did not provide basic care and services by assisting AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment for AV, which is a violation of Oregon Administrative rules.