Print Violation: 00231732-AP-189553

Provider Information

Tanner Spring Memory Care

23000 HORIZON DRIVE
West Linn, OR 97068

Date: 11/13/2022
Report number: 00231732-AP-189553
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
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: The facility failed to properly train staff on how to lift a resident who is care planned as a two person assist by hoyer lift. Based on facility documentation, the facility's lift policy includes staff training to be provided by a medical professional. An investigation determined that Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were not properly trained by a medical professional prior to assisting Alleged Victim (AV) with a transfer by hoyer lift which resulted in AV falling out of his/her Hoyer sling, hitting his/her head on the hoyer lift base causing a head injury, and being sent to the hospital for treatment. The facility's failure to provide a safe environment for AV resulted in pain and unreasonable discomfort to the AV which is a violation of resident rights, is considered neglect of care and constitutes abuse. AP2 and AP3 allegedly neglected AV when AP2 and AP3 failed to provide a safe environment for AV during a transfer by hoyer lift. An investigation determined no abuse occurred by AP2 and AP3.
Sanction: RCFCP23-00635 $1500.00 fine assessed