Violation Details: 00431160-AP-382959

Records Request Print
Date
9/28/2025
Report number
00431160-AP-382959
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) is a known fall risk and has suffered multiple falls over two months, and most recently suffered three falls in three days. AV's care plan states he/she has no impairment, although AV could not remember any falls, the care plan also states minimal assistance for mobility and independent in transfers, although AV suffered multiple falls in a short period of time. On or about October 2, 2025, AV suffered a fall in his/her room resulting in a skin tear to the forehead and upper extremities. AV was transferred to the hospital and discharged to a skilled nursing facility. Respondent failed to properly care plan to ensure AV was safe from suffering falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
ALFCP26-00305 $250.00 fine assessed