Print Violation: 00083633-AP-062307

Provider Information

Brookdale Bend

1099 NE WATT WAY
Bend, OR 97701

Date: 5/13/2020
Report number: 00083633-AP-062307
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: Alleged Victim (AV) is care planned to be checked on for toileting needs and fall risk every two hours during night shift. On or about May 13, 2020, at around 6:00 am during rounds, staff found AV on the floor with blood all over the floor and bathroom from AV's head and Face. AV was transported the hospital and diagnosed with a nose fracture and multiple abrasions to his/her face. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were responsible for checking on AV and both admitted to not completing the task. AP2 and AP3 failed to follow AV's care plan which is considered neglect of care and is abuse. The facility failed to ensure AV's care plan was followed which is a violation of Oregon Administrative Rules.