- Date
- 6/8/2025
- Report number
- 00436700-AP-388556
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) had suffered recent falls during the month of June 2025. Incident report dated June 16, 2025, indicated that AV suffered 4 falls in 30 days. Interventions included bracelet pendant, non skid socks and frequent safety checks. AV suffered two more falls on June 18, 2025, which no new interventions were noted. On or about June 19, 2025, AV was found by the morning caregiver on the floor in his/her room. It appeared that AV was on the floor all night, as AV's bed was made, and AV does not have the ability to make his/her own bed. AV had bruising scattered across both knees, right hip, left arm and left shoulder. AV was sent to the hospital. AV's service plan indicated that AV was completely independent and does not need safety checks. Respondent failed to properly care plan for AV's needs, leading to AV suffering unreasonable discomfort and pain. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP26-00139 $1500.00 fine assessed