- Date
- 4/15/2026
- Report number
- 00471704-AP-424040
- 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) suffered three falls within 2 days. AV's physician noted concern on March 31, 2026, regarding AV's increased fall risks. No changes were made to AV's care plan to ensure AV's risk of falls, and the interventions put into place were not progressive to ensure AV's safety. On or about April 15, 2026, after AV's third fall in as many days, AV was found by family to have a large goose egg on his/her head, which was bruised. AV was sent to the hospital and it was determined that AV has had a recent cognitive decline, which could have occurred due to the three most recent falls that AV suffered. Respondent failed to ensure AV's care plan was updated after AV was determined to be a fall risk and ensure interventions in place were progressive and appropriate to ensure the safety of this resident, placing AV at risk for serious harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- ALFCP26-00260 $500.00 fine assessed