Violation Details: 00429038-AP-380755

Date
9/5/2025
Report number
00429038-AP-380755
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Findings
The Alleged Victim (AV) is a known fall risk and has suffered multiple falls between July 29, 2025, and September 14, 2025. Although AV wasn't injured in these falls, AV was placed at risk for harm. AV was care planned to receive checks every two hours, including hygiene and person care during those checks. AV's care plan was not updated to have new interventions for falls until AV's most recent falls in September. The respondent failed to implement meaningful interventions to reduce AV's falls, placing AV at risk for serious harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
Sanction
ALFCP26-00093 $500.00 fine assessed