Violation Details: 00436790-AP-438716

Records Request Print
Date
10/20/2025
Report number
00436790-AP-438716
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) suffered a large bruise on his/her back of unknown origin. The bruise was noted on a skin sheet on October 26, 2025, and again on October 30, 2025. On November 4, 2025, AV had a large bruise in the middle of his/her back. On November 17, 2025, the bruise was still noted to be on AV's back. At no time was AV placed on alert charting for the large bruise on his/her back. By the time the RN provided a skin check on November 26, 2025, the bruise had resolved. Respondent failed to ensure staff followed protocol to ensure the resident was placed on alert charting to monitor a large bruise of unknown origin, or to put interventions in place to ensure AV did not suffer more bruises. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00673 $250.00 fine assessed