Violation Details: 00437072-AP-388915

Records Request Print
Date
11/5/2025
Report number
00437072-AP-388915
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to properly plan care
Result
Substantiated
Rule(s) Violated
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings
The Alleged Victim (AV) was a known fall risk, however, AV was not care planned as a fall risk. On or about November 5, 2025, AV was discovered to have gotten up from bed on their own and suffered a fall in his/her bathroom, which resulted in a skin tear to his/her elbow. Respondent failed to implement interventions to ensure the safety of AV, and reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i)
Sanction
RCFCP26-00353 $375.00 fine assessed