- Date
- 7/22/2024
- Report number
- 00343978-AP-294469
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- On or about July 22, 2024, Alleged Victim (AV) fell in the facility's dining room when Alleged Perpetrator 2 (AP2) assisted AV to the dining room for his/her mealtime. Based on facility documentation and interviews, AP2 became distracted with another resident while actively assisting AV, and left AV standing up on his/her own without completing the task of transferring AV to the dining room chair. As a result of AP2's actions, AV immediately lost balance and fell to the floor, hitting his/her head. AV experienced vomiting, head pain, and right hip pain as result of the fall. AV was sent to the hospital for treatment and later returned to the facility with a diagnosis of head injury and emesis. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the supervision and overall conduct of staff when staff are acting within the scope of his/her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.