- Date
- 3/31/2025
- Report number
- 00437723-AP-389568
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) was found on the floor near his/her room after yelling for help. AV did not have a pendant to call for help as it was removed from his/her, and a baby monitor was installed. The monitor was to be monitored from the medication room, however, much of the time, no one was in the medication room to monitor it. AV suffered a skin tear from the fall. Later that day, AV was sent to the hospital for increasing pain to his/her knee and thigh. AV's service plan lacked guidance for safety checks or tracking when AV was last seen. Respondent failed to ensure staff were monitoring AV or completing safety checks to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).