- Date
- 9/11/2025
- Report number
- CALMS - 00094261
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 11/04/25, the facility’s failure to ensure reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents was substantiated for 1 of 1 sampled resident (#1). Resident 1’s wheelchair was not securely locked resulting in an injury fall and subsequent decline. Findings include, but are not limited to:
An incident report dated 09/11/25, indicated the following:
· Resident 1 was struggling with behaviors;
· Staff 2 offered to take Resident 1 on a walk outside as a 1 on 1 intervention for behaviors;
· Resident 1 was wheeled to the parking lot onto the sidewalk;
· Staff 2 retrieved polish remover from his/her car;
· Resident 1’s wheelchair was not securely locked;
· Wheelchair went off the curb resulting in resident falling out of his/her wheelchair on to the pavement;
· Resident 1 hit his/her head on the pavement;
· Resident 1 was bleeding from the left side of their face; and
· Paramedics were called.
Progress notes dated 09/11/25, indicated the following:
· Resident 1 was between two car spaces laying face down and bleeding from left side of face;
· Resident 1 came back from ER with a left orbital floor fracture and facial contusions; and
· Resident 1 was in a lot of pain.
A progress note dated 09/12/25 at 10:00 am, indicated Staff 2 thought s/he engaged the wheelchair brakes to grab something from his/her vehicle and one of the brakes wasn’t engaged all the way resulting in the wheelchair rolling off the curb and causing resident to fall face first onto the pavement.
Staff 2 stated:
· Resident 1 was having behaviors;
· S/he asked Resident 1 if they wanted to go for a walk and Resident 1 said yes;
· S/he wheeled Resident 1 outside onto the curb;
· S/he retrieved an item from his/her car;
· Resident 1’s wheelchair brake was not locked all the way; and
· Resident 1’s wheelchair went off the curb.
Staff 1 stated Staff 2 was verbally counseled regarding Resident 1 being harmed. Verbal counseling documentation dated 09/12/25, indicated improper wheelchair brake use resulted in resident harm. A progress note dated 09/18/25, indicated the following:
· Resident 1’s health quickly declined after the fall despite going to the emergency department and being attended to medically;
· Resident 1 was admitted to hospice 09/17/25; and
· Resident 1 passed away 09/18/25.
The investigation determined the facility failed to exercise reasonable precautions against any condition that threatened the health, safety, or welfare of residents which is a violation of Oregon Administrative Rules.