Violation Details: 00444065-AP-396047

Records Request Print
Date
12/10/2025
Report number
00444065-AP-396047
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious 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)
External site: 411-054-0040(1)(a) and (d)
Findings
The Alleged Victim (AV) has a catheter and has been diagnosed with multiple urinary tract infections and one bout of sepsis throughout 2025. Staff are to ensure that AV's catheter is changed once per month. AV went a couple of months in 2025 without a catheter change. AV has a history of refusing catheter care and the only intervention in place was to apply a change of face or wait a few minutes and try again. AV suffered unreasonable discomfort due to not getting complete catheter care. Respondent failed to ensure appropriate interventions were in place to ensure timely catheter care was completed. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00140 $1500.00 fine assessed