- Date
- 1/3/2025
- Report number
- 00375700-AP-326086
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is care planned to have a fall mat in his/her room to alert staff when and if AV falls, as AV has a history of falls from self-transferring. On or about January 3, 2025, Alleged Perpetrator #2 (AP2) turned off AV's fall mat because it was malfunctioning. AP2's actions resulted in AV suffering a fall and sustaining a bruise to his/her ankle and staff were not aware of the fall. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.