- Date
- 4/17/2025
- Report number
- 00396711-AP-347367
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- On or about April 17, 2025, Alleged Perpetrator 2 (AP2) gave Alleged Victim (AV) peanut butter bread during snack time causing AV to choke. AV is care planned as requiring food restriction for Mechanic Soft foods, no bread, and no meat. Based on facility documentation and interviews, AV choked on the peanut bread causing blockage to AV's airway and causing AV to turn blue and needing the Heimlich to dislodge the bread. AP2 failed to follow restriction for AV giving AV peanut butter bread, causing AV to choke, resulting in physical harm and unreasonable discomfort. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide oversight to prevent AV from being provided bread to eat resulting in AV choking which is considered to be a violation of Oregon Administrative Rules.
- Sanction
- RCFCP25-00934 $1500.00 fine assessed