Violation Details: 00369105-AP-319351

Records Request Print
Date
11/29/2024
Report number
00369105-AP-319351
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 care planned for two hour safety checks during night shift. On or about November 29, 2024, AV fell from his/her bed at approximately 12:40 am. Alleged Perpetrator #2 (AP2) was working night shift that night, and failed to follow the care plan to complete safety checks on AV. AV was found at approximately 3:00 am, on the floor, AV waited over 2 hours for assistance. 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 followed, which is a violation of Oregon Administrative Rules.