- Date
- 12/13/2024
- Report number
- 00372304-AP-322657
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide inservice
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about December 13, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not correctly place a pad alarm under AV while seated, resulting in AV being placed at risk of serious harm and experiencing a fall with hospitalization. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.