- Date
- 12/27/2025
- Report number
- 00454615-AP-406739
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- The Alleged Victim (AV) is a known fall risk and has suffered multiple falls over a few months. On or about December 27, 2025, AV suffered a fall out of his/her bed and sustained a skin tear and a bruise. AV was on two hour safety checks and was prescribed a wheelchair to assist with increased weakness and falls. AV's care plan stated that AV was independent with ambulation and transfers, and did not require assistance with safety checks or fall prevention measures. Hospital bed with rails were requested but have not been implemented. Respondent failed to ensure AV's care plan was updated with current information and ensure interventions were in place to reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00350 $500.00 fine assessed