Violation Details: 00402538-AP-353445

Records Request Print
Date
5/16/2025
Report number
00402538-AP-353445
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide service
Result
Substantiated
Rule(s) Violated
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0030(1)(e)(G)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) was care planned for 2 hour checks to check and change his/her brief and to empty AV's catheter. Staff were not regularly providing personal cares or emptying AV's catheter. From approximately May 16, 2025, to May 19, 2025, AV's brief was not changed by staff and on May 19, 2025, AV was found to be soaked as his/her catheter was leaking and AV's skin was very red, causing unreasonable discomfort. Respondent failed to ensure staff followed the service plan to change AV's brief, causing unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00243 $188.00 fine assessed