- Date
- 1/27/2025
- Report number
- CALMS - 00084926
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during site visits on 03/07/25 and 03/12/25, the facility’s failure to document action or intervention needed for change of condition and to monitor until the condition resolves was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
The following documents were reviewed for Resident 1:
Service plan dated 12/03/24.
Temporary service plans (TSPs) from 12/12/24 through 02/10/25.
Progress notes dated 12/01/24 through 02/28/25.
Event reports for 12/12/24, 12/29/24, and 1/27/25.
Hospital discharge paperwork from 01/28/25 and 02/10/25.
Monitoring case history from 12/01/24 through 03/07/25.
Resident 1’s records indicated the following:
Resident 1 experienced a fall on 12/12/24, 12/29/24, and 01/27/25.
The facility had not documented at least weekly, until it was determined, and recorded that the conditions resolved for the falls that occurred on 12/12/24 and 12/29/24.
No documented evidence that the facility monitored the status of the following injuries at least weekly until they were noted to be resolved.
The resident was identified with a bump to the left shoulder blade following the fall on 12/29/24.
Two bruises to the right forearm and a bruise to the left side of the forehead following the fall on 1/27/25.
The facility had not fully evaluated the circumstances of the fall on 01/27/25, to determine whether the current service-planned fall interventions were adequate or whether additional interventions needed to be developed and implemented.
An interview with Staff 1 and Staff 2 was conducted. Both staff acknowledged weekly monitoring had not been completed.
The findings were reviewed with and acknowledged by Staff 1 on 03/07/25. The facility’s failure to document action or intervention needed for change of condition and to monitor until the condition resolves was substantiated. The facility's failure is a violation of Oregon Administrative Rules.