Violation Details: 00356249-AP-306581

Records Request Print
Date
9/22/2024
Report number
00356249-AP-306581
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2), 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility to meet his/her daily needs and is care planned to have three care staff assist with transfers for toileting. According to an investigation, on or about September 22, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not call for assistance with transferring AV to the toilet, provided transfer assistance to AV and fell during the transfer, resulting in AV falling, having skin tears to his/her legs and experiencing unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to follow the service plan, which violates Oregon Administrative Rules.