- Date
- 10/10/2024
- Report number
- 00360567-AP-310949
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- Alleged Victim (AV) relies on the facility for his/her care. AV is a fall risk and is care planned to have a fall mat placed next to their bed when they are in it. On or about October 10, 2024, Alleged Perpetrator #2 (AP2) helped AV into bed for a nap, and did not place the fall mat beside AV's bed. A few hours later AV was found on the floor bleeding from a laceration on top of their head, and abrasions on their right forearm, leg and side. AV was transported to the hospital and needed multiple staples to close the head laceration. AP2 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.