- Date
- 4/26/2024
- Report number
- OR0005008600
- 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 a Licensing Compliant Unit (LCU) site visit on May 13, 2024, and May 14, 2024, it was determined the facility failed to ensure Alleged Victim's (AV) monitoring and reporting system was implemented 24-hours a day. A review of AV's progress notes dated April 3, 2024, through May 13, 2024, and Temporary Service Plans dated April 6, 2024, through April 30, 2024, revealed on April 18, 2024, that AV's PCP was contacted related to concern for a urinary tract infection and other skin issues, and that on April 20, 2024, AV was also treated for constipation. Based on facility documentation, there was no documented evidence of written communication of AV's change of condition, and any required interventions, for direct care staff on each shift. The facility's failure to provide oversight and monitoring when AV's condition changed by ensuring staff knew how to follow-up on AV's change of condition is a violation of Oregon Administrative Rules.