- Date
- 5/29/2024
- Report number
- 00333846-AP-284893
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV)Service plan indicates AV requires staff for hands on assist with all activities of daily living. AV uses a wheelchair for mobility and requires staff to assist with ambulation. AV is a 3 person hands on transfers. AV has been provided a support bar and staff is to use gait belt for all transferring. A note was made that 2 person transfers may lead to risk of injuries and falls. AV is a high fall risk and requires staff to assist with activities of daily living. AV can notify staff when needing assistance with the use of call device. On or about May 29, 2024, AP2 attempt to transfer AV from bed area to wheelchair. AV fell on the floor of their home during transfer attempt. AV was able to identify fall and did not express of any pain or discomfort. Alleged Perpetrator 2 (AP2) shared that AP2 called for another Staff to assist with a transfer multiple times and no one showed up. AV shared that AP2 had called for additional [Staff] to assist, and no one showed up to assist AP2 with the transfer. AV shared that they could not wait any longer and insisted that AP2 transfers them. The facility failed to ensure the care plan was being followed, a safe environment for AV, and have appropriate staffing to meet the scheduled and unscheduled needs of the resident which is a violation of Oregon Administrative Rules.