Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00197227-AP-158181
Provider Information
Klamath Falls Senior Living
2130 N ELDORADO AVE
Klamath Falls, OR 97601
- Provider ID
- 70M024
- Administrator
- Eileen McCoy
- Phone
- (541) 882-4830
- ed.klamathfalls@klamathfallsseniorliving.com
Violation Details
- Date
- 4/29/2022
- Report number
- 00197227-AP-158181
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- 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)
External site: 411-054-0040(1)(b) and (c)
External site: 411-054-0045(1)(f)
- Findings
- AV has a history of periodic hip pain and experienced approximately five falls between December 4, 2021 and April 23, 2022. On or around April 19, 2022, AV's hip pain worsened significantly and interfered with AV's ability to ambulate. AV complained of extreme weakness and trouble walking, and was observed walking with a wobble. For subsequent days facility staff documented AV's continued complaints of pain and difficulty ambulating. On April 23 and April 27, 2022, AV fell in the facility. AP2 was notified of these changes and considered them to constitute a significant change of condition as defined in 411-054-0040(1)(b). AP2 failed to assess or appropriately respond to AV's significant change of condition according to 411-054-0045(1)(f) or document any contact with AV's primary care physician--thus suggesting that AV's primary care physician was not contacted. The facility failed to oversee staff and ensure that staff followed the applicable regulations and provided appropriate care. Failure to timely respond to, assess, and follow-up on treatment related to AV's significant change of condition constituted a failure to provide basic care and services as required by rule, resulting in a risk of serious harm to the resident through the continued risk of falls as well as harm to the resident in experiencing ongoing pain. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).
- Sanction
- ALFCP22-00882 $375.00 fine assessed