- Date
- 5/31/2024
- Report number
- 00334374-AP-285391
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) has a history of falls and is known to self-transfer. AV is care planned for one-person assist for transfers and for staff to offer toileting assistance after meals. According to an investigation, on or about, May 31, 2024, Alleged Perpetrator 2 (AP2) witnessed AV going to his/her room after dinner and shutting his/her door and did not check on AV or offer toileting assistance. AV experienced an unwitnessed fall when he/she attempted to self-transfer, resulting in a laceration above the eyebrow and skin tears on each arm. 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.