- Date
- 9/23/2024
- Report number
- 00356496-AP-306831
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Alleged Victim (AV) is known to attempt to ingest foreign substances. On or about September 17, 2024 AV was found with an open bottle of conditioner lifted to AV's mouth. Witness 2 (W2) took the bottle of conditioner from AV. It is unknown how much conditioner was consumed by AV, if any at all.
W2 informed Alleged Perpetrator 2 (AP2), AV may have consumed some conditioner. AP2 advised W2 to put AV on alert charting and implement a Temporary Care Plan, but did not implement any further interventions. Poison Control was not called to determine if AV needed to be sent to the hospital for evaluation.
It is AP1's policy to call poison control after a suspected poisoning due to ingesting unknown or foreign substances. Employees are also expected to inform the executive director of all incidents and write an incident report, neither of which were done by AP2. The risk of harm to AV by drinking conditioner would be nausea, vomiting, and diarrhea. AP2 did not follow AP1's policy, and did not provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment, which is a violation of Oregon Administrative rules.