Violation Details: 00395719-AP-346411

Records Request Print
Date
4/15/2025
Report number
00395719-AP-346411
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to provide safe environment
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(s)
Findings
On or about April 15, 2025, Alleged Victim (AV) fell in the bathroom when Alleged Perpetrator 2 (AP2) was transferring AV, causing AV to fall on his/her left knee. Based on facility documentation and interviews, AV is service planned as a two-person transfer. AP2 failed to follow AV's service plan when transferring AV caused AV to suffer a fall that fractured his/her knee due to a fall during a transfer. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.