Violation Details: 00382182-AP-332714

Records Request Print
Date
2/6/2025
Report number
00382182-AP-332714
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide oversight and monitoring of change of condition
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: 411-054-0040(1)(a) and (d), (2)
Findings
The Alleged Victim (AV) has multiple chronic wounds, and staff are to document or report any new or worsening wounds. On or about February 6, 2025, staff informed home health of an untreated wound on AV's right hip. Staff claims to have notified other facility staff a couple weeks prior, however, no documentation exists of this occurring. AV's wound was unstageable and necrotic on February 6, 2025, when reported to home health. Had the wound been followed up on earlier, treatment options would have been available to prevent the wound from degrading to the level it was found by home health. Respondent failed to ensure staff followed protocol to ensure nursing staff were made aware of a change of condition, causing AV unreasonable discomfort. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00065 $375.00 fine assessed