- Date
- 1/4/2025
- Report number
- 00375447-AP-325853
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On January 6, 2025, Oregon Department of Human Services (ODHS) Adult Protective Services (APS) conducted Investigation #00375447 and issued a written report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility. On December 31, 2024, AV experienced a fall that resulted in hospitalization. Upon discharge on January 3, 2025, hospital instructions directed facility staff to check on AV four times per shift to ensure AV’s health and safety. Based on facility documentation and staff interviews, APS determined that the facility failed to adequately train staff to implement the post-discharge care instructions. During the NOC shift from January 3 to January 4, 2025, staff did not perform the required checks on AV. This failure was attributed to insufficient staff training and a lack of administrative oversight. The facility’s failure to ensure staff were properly trained and equipped to follow AV’s care plan caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.
- Sanction
- ALFCP25-01080 $375.00 fine assessed