Print Violation: 00167477-AP-132833

Provider Information

Pelican Pointe

615 WASHBURN WAY
Klamath Falls, OR 97603

Date: 10/13/2021
Report number: 00167477-AP-132833
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: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
Findings: On or about October 13, 2021, the Alleged Victim (AV) was outside smoking and fell into some bushes, sustaining scratches on his/her arms, legs, forehead and the top of his/her head. Alleged Perpetrator #2 (AP2) was supposed to escort and supervise AV while he/she was outside smoking. AP2 returned to the building because it was cold, leaving AV alone outside while he/she watched through a window. At some point, AP2 was distracted by other staff and was not watching AV when he/she fell. AP2's actions placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.