Violation Details: 00454794-AP-406905

Records Request Print
Date
1/31/2026
Report number
00454794-AP-406905
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to follow care plan
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) is a two person assist for all transfers and is care planned with a pressure alarm for AV's safety, and staff are to test AV's pressure alarm each shift and ensure it is working properly. On or about January 13, 2026, AV suffered a non-injury fall while transferring to the toilet. AV's pressure alarm did not go off. Staff signed off that they checked AV's pressure alarm, however, staff thought the pressure alarm was working, when the batteries were dead in AV's pressure alarm. Respondent failed to ensure staff understood how to check the pressure alarm and know when batteries needed to be replaced, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).
Sanction
RCFCP26-00392 $375.00 fine assessed