Violation Details: 00346207-AP-296647

Date
8/4/2024
Report number
00346207-AP-296647
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide safe environment
Result
Substantiated
Findings
Alleged Victim (AV) relies on the facility for h/h care. AV has a history of falls. Hospice provided an alarm for AV's bed on or about July 8, 2024. According to AVs care plan, AV is supposed have the the alarm under h/h at all times, bed, wheelchair and recliner. On or about August 4, 2024, Alleged Perpetrator 2 and 3, toileted AV, and placed AV in a recliner in the living room. According to AP1 the camera video footage was viewed, which showed AV trying to get up, and s/he fell to h/h side/back and possibly bumped the back of h/h head. AP2 and AP3 did not take AV's pressure alarm from h/h apartment and did not place the alarm back under AV in the living room. AP2 and AP3 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.
Sanction
RCFCP25-00878 $375.00 fine assessed