Violation Details: 00368793-AP-319069

Records Request Print
Date
11/26/2024
Report number
00368793-AP-319069
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious 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) relies on the facility for care and is service planned for the assistance of two to three caregivers when transferring and toileting. On or about November 26, 2024, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan of having two trained staff to assist with transferring, nor did AP2 request the assistance of additional staff when the AV expressed weakness. The AV fell, was transported to the hospital and diagnosed with an unstable back fracture with the risk of becoming permanently paralyzed. The AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.