Violation Details: 00364978-AP-315253

Records Request Print
Date
11/3/2024
Report number
00364978-AP-315253
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
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: 411-054-0030(1)(e)(A)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a known fall risk and has suffered 5 falls with injury between September 2024 and November 2024. AV's most recent fall was on November 3, 2024, staff saw AV walking independently but did not assist AV with ambulation to prevent a fall. AV suffered a bump to his/her head. After each of AV's previous falls, staff were to check on AV hourly and encourage AV to use his/her call light and wait for staff. According to documentation, it is known that AV has trouble remembering. Respondent failed to ensure progressive interventions were implemented to ensure AV's safety from falling. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00460 $500.00 fine assessed