- Date
- 12/3/2024
- Report number
- 00372335-AP-322695
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) service plan resulting in the AV to suffer a fall. On or about December 03, 2024, AP2 was assisting the AV in the bathroom. The AP2 left the AV alone to go to the other room and they heard the AV fall. The AV was a known fall risk and was service planned to not be left alone while standing. The AP2 stated they did not read the AV’s service plan and had not assisted the AV for approximately 1-2 months. The AV was diagnosed with a fractured rib due to the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the service plan was being followed, which is a violation or Oregon Administrative Rules.