Violation Details: 00417918-AP-379887

Records Request Print
Date
7/15/2025
Report number
00417918-AP-379887
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate 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) suffered 2 falls between July 26, 2025, and July 28, 2025. AV's care plan was not updated to reflect AV's need to have stand by assistance with ambulation and transfers. AV's care plan was not updated until July 31, 2025. AV continued to fall through August 28, 2025, with two more falls. Respondent failed to ensure proper care planning and that 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
RCFCP26-00039 $1000.00 fine assessed