Violation Details: 00396457-AP-347102

Records Request Print
Date
4/18/2025
Report number
00396457-AP-347102
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to follow care plan
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0070(1)
Findings
The Alleged Victim (AV) is a known fall risk. On or about April 18, 2025, AV was found on the floor of his/her apartment covered in blood with a head wound and covered in feces. AV is care planned to be checked on for safety 8 times per shift. Staff called emergency services, and it was noted that it appeared AV had been on the floor for some time. It was determined the last check on AV was at 4:00 am, so AV had been on the floor for at least 6 hours. Staff noted that the facility was short staffed. AV was transported to the hospital where he/she received staples to his/her forehead to treat the laceration. The Respondents failure to follow the care plan for AV's risk of falls caused AV to lay on the floor for multiple hours with an injury to his/her head. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00033 $375.00 fine assessed