Violation Details: 00412390-AP-429313

Records Request Print
Date
7/7/2025
Report number
00412390-AP-429313
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Allegation
Failed to properly plan care
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)
Findings
The Alleged Victim (AV) is full assist with mobility and transfers. During the time frame of May 13, 2025, through July 7, 2025, AV suffered eleven falls, with four of those falls resulting in injury. On or about June 16, 2025, AV suffered a fall that resulted in a closed fracture to his/her left arm. Between May 13, 2025, and July 3, 2025, only two new interventions were put into place to reduce falls, which were not effective in reducing falls. Respondent failed to ensure interventions were in place to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00293 $1500.00 fine assessed