Print Violation: 00047286-AP-032990

Provider Information

Prestige Senior Living Riverwood

18321 SW PACIFIC HWY
Tualatin, OR 97062

Date: 9/1/2019
Report number: 00047286-AP-032990
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0040(1)(b) and (c)
Findings: Alleged Victim (AV) is care planned for assistance with preparing for bed each night and is care planned for his/her catheter to be checked at least one time per shift. On or about August 31, 2019, at approximately 9:35pm AV fell outside sustaining injuries. Alleged Perpetrator 2 (AP2) assisted AV after the fall and noted that AV seemed more confused then normal. This information was not clearly communicated during shift change. On or about August 31, 2019, 10:30pm through September 1, 2019, 730am AV was not checked on. AV was found in his/her room on the floor. AV had fallen forward and landed face down with his/her wheelchair on top of him/her. AV's bed was still made up and his/her catheter bag was full. AV was transported to the hospital for treatment. AP2 failed to respond appropriately to AV's change of condition and the facility failed to ensure AV's care plan was followed which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP20-00245 $1500.00 fine assessed