Violation Details: 00392381-AP-342947

Records Request Print
Date
3/31/2025
Report number
00392381-AP-342947
Type
Licensing Violation
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)(s)
Findings
According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the care plan for the Alleged Victim (AV) by self-transferring the AV. on or about February 20, 2025, the AV’s service plan was updated to reflect they were now a 2-person transfer. Training on proper gait belt use was provided to staff after the service plan update. On or about March 30, 2025, the AP2 was assisting the AV when they attempted to self-transfer the AV. The AV suffered a fall and sustained an injury to their back, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules