Violation Details: 00332939-AP-284094

Records Request Print
Date
5/22/2024
Report number
00332939-AP-284094
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
Findings
On or about May 22, 2024, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with a transfer using the PAL lift. AP2 was trained on how to use the lift with residents. While AP2 was using the lift, AP2 failed to position the lift correctly, failed to lock the lift legs in the correct position and failed to set the wheelchair brakes prior to transferring AV. During the transfer, the lift fell onto AV, causing facial injuries, including a fractured nasal bone. AV was sent to the emergency room and returned with pain medication. AP2's failure to properly transfer AV is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.