Violation Details: 00420208-AP-371580

Records Request Print
Date
8/12/2025
Report number
00420208-AP-371580
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to provide inservice
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0070(2)
Findings
On or about August 12, 2025, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) were assisting AV with a two person transfer to his/her hospital bed. AV's current bed had a bed can that was not removable. Upon transferring AP2 and AP3 did not use a draw sheet to transfer AV, which is to be used when the resident does not have the ability to follow directions or assist with keeping arms at their chest. During the transfer, AV's arm slipped and wrapped around the transfer pole, causing a skin tear to AV. Respondent failed to ensure staff were properly trained to ensure the safety of residents during a transfer. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00092 $169.00 fine assessed