- Date
- 8/25/2025
- Report number
- 00422860-AP-374352
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) was bedbound, frail and unable to move independently. AV was care planned as a one-person transfer with a gait belt. On or about August 25, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with a transfer and requested assistance from another staff member. The other staff member encouraged AP2 to transfer AV by him/herself from the wheelchair to his/ her bed, by lifting AV under his/her arms and completing the transfer. In the process of the transfer, AV hit his/her arm on the wheelchair, causing multiple bruising to his/her left forearm. Facility documentation lacked any training records for AP2 regarding safe transfers or gait belt training. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse as outlined in OAR 411-020-0002(1)(A)(i). The facility's failure to ensure that staff are trained properly on resident's care plans and have completed training to provide all aspects of resident's care, places residents at risk for harm.
- Sanction
- ALFCP25-01088 $188.00 fine assessed