Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00223286-AP-181921
Provider Information
Bonaventure of Tigard Assisted Living
15000 SW HALL BLVD
Tigard, OR 97224
- Provider ID
- 70A301
- Administrator
- Jennifer Ruljancich
- Phone
- (503) 214-4200
- executivedirectortig@livebsl.com
Violation Details
- Date
- 9/17/2022
- Report number
- 00223286-AP-181921
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
- Findings
- Alleged Victim (AV) has been diagnosed with diseases that cause allover muscle weakness. AV needs support from caregivers to meet basic daily needs. AV is full assist for toileting, dressing, grooming and transfers. AV’s care plan states he/she will push his/her pendant when he/she is ready to change into his/her night clothes and is ready for bed and staff are to help AV into bed. On or about September 17, 2022, AV did not want to go to bed, and it was not communicated to NOC shift that AV had not been put into bed. Alleged Perpetrator 2 (AP2) left early before NOC shift arrived. AV called for help the night of September 17, 2022, at 10:42pm, but the call went unanswered for over an hour before it was shut off, AV kept waiting for someone to come back and help. On or about September 18, 2022, AV was found in his/her wheelchair by a staff member in a t-shirt, wet brief, cold to the touch and was disoriented. NOC shift duties include physically checking on certain residents including AV. AP2 did not leave any communication to the oncoming staff that AV was still up and not in bed. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 5 (AP5) did not check on AV the entire NOC shift. The expectation is that staff are to check on residents throughout the shift. AP2, AP4 and AP4 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP23-00609 $500.00 fine assessed