Violation Details: 00384632-AP-335163

Records Request Print
Date
2/19/2025
Report number
00384632-AP-335163
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
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: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is a known fall risk and is care planned to have a pressure alarm under him/her while in his/her wheelchair. On or about February 19, 2025, AV returned from his/her physician appointment and staff failed to place AV's pressure alarm under them. AV was in the common area and stood up and took about 4 steps and fell to his/her hands and knees. AV sustained skin tears to his/her hands and knee. Respondent failed to ensure staff followed the service plan to have AV's pressure alarm in place to reduce falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00051 $188.00 fine assessed