- Date
- 6/20/2025
- Report number
- 00409564-AP-360633
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a full assist with mobility. AV is care planned to be transferred using his/her walker to transfer him/her to their wheelchair. AV is also care planned to have non skid socks on during transfers. On or about June 20, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with going to the bathroom. AP2 did not transfer AV to his/her wheelchair, instead used AV's walker to escort AV to the bathroom. AV was not wearing non skid socks. AV stated they weren't able to continue walking and became unsteady. AV began to fall and AP2 assisted AV to the floor. AV immediately cried out "my foot, my foot". AV was transferred to the hospital and diagnosed with a fractured ankle. AP2's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure care plans are followed is a violation of Oregon Administrative Rules.