Print Violation: 00120097-AP-093201

Provider Information

Pelican Pointe

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 1/11/2021
Report number: 00120097-AP-093201
Type: Abuse: Neglect
Level: 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
Allegation: Failed to intervene when resident's condition changed
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(20: 411-054-0030(1)(e)(I)
External site: 411-054-0040(1)(b) and (c)
Findings: The Alleged Victim (AV) was dependent for toileting cares and was to be toileted by staff up to six times per day. On or about January 9, 2021, it was noted in documentation that AV had an open sore on his/her coccyx, however, there were no directions for care for this wound. On or about January 11, 2021, the AV was found to have a wound on his/her coccyx, measuring approximately 10 cm x 8 cm by 2 cm and was black. AV was transferred to the hospital for treatment and the wound was found to be necrotic, infected and septic. The facility's failure to intervene when a residents condition changed is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP21-02786 $2500.00 fine assessed