- Date
- 5/25/2025
- Report number
- 00415491-AP-383140
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to provide care and services necessary to ensure the safety of AV. AV has a history of falls, including a fall on April 29, 2025, while getting out of the shower which resulted in an abrasion to AV's right elbow. In additional AV fell in Witness #1 (W1) bathroom on May 21, 2025, AV was not conscious when found and seen at the Emergency Room. AV had two additional non-injury falls on April 28, 2025, and May 4, 2025. AV's progress notes reflect AV is unsteady while standing and needing stand by assistance with toileting. However, the facility failed to develop sufficient interventions to mitigate risk to AV. On or about June 11, 2025, AV fell in AV's room hitting AV's head. AV reports being very painful in AV's neck, left shoulder, and back. AV also has redness on AV's knees and complains of pain in AV's knees. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP25-01483 $500.00 fine assessed