- Date
- 10/1/2024
- Report number
- 00357771-AP-308128
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The facility failed to implement appropriate interventions related to the Alleged Victim’s (AV) known history of falls. On or about October 1, 2024, AV was found by facility staff on the floor leaning against AV's bed. Prior to incident, AV reportedly had just returned to the facility from a recent hospitalization on September 30, 2024. AV was hospitalized due to continued falls and complaints of chest and rib pain. Based on facility documentation and interviews, facility staff had completed a safety check on AV, with no identified concerns ten minutes prior to incident. AV's service plan dated September 14, 2024, states AV experienced 18 falls since May 2024. AV did not experience pain, harm, or negative outcome as a result of the incident. However, AV is a known fall risk, and had just returned to the facility after a hospitalization for falls. The facility failed to implement appropriate interventions for AV's fall risk, resulting in AV experiencing repeated falls since May 2024. The facility's failure to properly care plan for AV's fall risk is a violation of Oregon Administrative Rules.
- Sanction
- RCFCP25-00681 $250.00 fine assessed