Violation Details: 00401278-AP-352173

Records Request Print
Date
4/19/2025
Report number
00401278-AP-352173
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to assist with transfer
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) relies on the facility to assist with transfers. AV's care plan instructed staff to use a slide board for transfers. According to an investigation, on or about April 19, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not use the sliding board during a transfer, resulting in multiple spinal fractures and AV experiencing pain and unreasonable discomfort, requiring hospitalization. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the service plan was followed during the transfer, which violates Oregon Administrative Rules.