Violation Details: 00357874-AP-308376

Records Request Print Provider Details
Date
10/1/2024
Report number
00357874-AP-308376
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide oversight and monitoring of change of condition
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0040(1)(a) and (d)
411-054-0045(1)(f)(A)
Findings
on or about September 24, 2024, the Alleged Victim (AV) reported to Alleged Perpetrator #2 (AP2), along with two other staff that he/she likely had a UTI and had for a while. AP2 told Witness #1 IW1) and Witness #2 (W2) that he/she planned to get AV tested for a UTI. On September 25, 2025, AP2 told APSS that AV needed to be sent out to the hospital for a urine analysis, for suspected UTI. On or about October 1, 2024, W1 returned to the facility and learned that AV had never been sent out or tested for UTI. AV was still complaining of the UTI, was in pain and not at baseline. AP2 never followed up on AV's complaints, did not complete an RN assessment, did not contact AV's PCP, POA or the hospital, nor did AP2 enter any of this information into the facility system. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a change of condition was addressed and monitored is a violation of Oregon Administrative Rules.