Violation Details: 00367052-AP-317288

Records Request Print Provider Details
Date
11/18/2024
Report number
00367052-AP-317288
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a known fall risk and had suffered previous falls with and without injury. On or about November 18, 2024, staff responded to AV's call light and found AV on the floor sitting position, with his/her back to his/her bed. AV was a one-person assist with transfers, however, there was no documentation indicating how staff were to implement it. AV tied to get up on his/her own and ambulate, which caused many of AV's falls. Respondent failed to implement interventions to reduce AV's risk of falls and ensure staff were aware how to enact the interventions that were in place. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00114 $375.00 fine assessed