Print Violation: 00222107-AP-180825

Provider Information

Courtyard at Mt Tabor Garden House

6323 SE DIVISION
Portland, OR 97206

Date: 9/17/2022
Report number: 00222107-AP-180825
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to intervene when resident's condition changed
Result: Substantiated
Rule(s) Violated: External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0040(1)(b) and (c)
Findings: On or about September 17, 2022, the Alleged Victim (AV) was noted to be expressing pain to his/her right arm and was given pain medication by Alleged Perpetrator #2 (AP2). AP2 did not do a pain assessment on AV at that time. On or about September 18, 2022, Alleged Perpetrator 3 (AP3) was notified by a staff member of AV’s pain and the need for AP3 to assess AV. AP3 did not observe or assess AV for any injuries that morning. AV’s physician was called in the afternoon by AV’s spouse and it was decided to take AV to the hospital where he/she was diagnosed with a dislocated shoulder and a fractured arm. AP2 and AP3’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure is a violation of Oregon Administrative Rules.