- Date
- 7/2/2025
- Report number
- 00412896-AP-364063
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- According to the documentation, the Alleged Perpetrator 3 (AP3) failed to answer the Alleged Victim’s (AV) call light timely, resulting in the AV falling and sustaining an injury. On or about July 03, 2025, the AV used the call system for help. According to the documentation, it took AP3 approximately an hour and four minutes to respond to the call light. During this time, the AV attempted to self-transfer and ambulate to the bathroom. During this attempt, the AV fell and received a wound to their leg. The AP3’s failure to respond to the call light timely is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure call lights were answered timely which is a violation of Oregon Administrative Rules.