Violation Details: 00364189-AP-314453

Records Request Print
Date
11/4/2024
Report number
00364189-AP-314453
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)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a know fall risk and is care planned to be assisted with transfers. On or about November 2, 2024, AV was in the TV room with Alleged Perpetrator #2 (AP2) when AV stood up from his/her wheelchair. AP2 advised AV to sit back down and when AV tried to sit, his/her wheelchair moved and AV fell to the floor. AP2 did not assist AV and did not assure that AV's wheelchair brakes were locked. AP2's failure to follow the care plan and assist AV with a transfer is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was being followed is a violation of Oregon Administrative Rules.
Sanction
RCFCP25-00237 $375.00 fine assessed