Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00236935-AP-194228
Provider Information
New Friends of Coos Bay
955 KENTUCKY AVE
Coos Bay, OR 97420
- Provider ID
- 50R491
- Administrator
- Jessi Caywood
- Phone
- (541) 808-9730
- ed@newfriendsofcoosbay.com
Violation Details
- Date
- 12/4/2022
- Report number
- 00236935-AP-194228
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide service
- 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
- Alleged Victim (AV) lived at Respondent’s facility. On or around August 9, 2022, AV’s primary care physician (PCP) noted an early pressure ulcer to AV’s posterior left heel. The PCP sent the facility orders to float AV’s heels and have AV wear protective slippers (aka “moon boots”). AV’s service plan required staff to implement those measures, and required staff to monitor AV’s skin for redness, apply lotion, and assist with showers twice a week. The service plan also indicated that Alleged Perpetrator #2 (AP2) needed to monitor AV’s skin. On or around October 17, 2022, the facility developed a Temporary Service Plan (TSP) with additional related services. However, witness statements and facility documentation demonstrate that showers and skin monitoring were not occurring at the frequency required by the service plan, and that the moon boots may have been misused. On or about December 4, 2022, AV was in pain when staff removed “sopping wet” moon boats and discovered a round black area on AV’s left heel. At that stage, AV’s heel condition had worsened into a Stage III or IV pressure ulcer and caused AV pain. Alleged Perpetrator #2 (AP2) actions and failure to provide supervision and monitoring of AV known pressure ulcer is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failure to ensure adequate supervision, oversight of staff, services, and failure to ensure AV service plan is followed, resulted in pain, unreasonable discomfort, and ulcer progression, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP23-00693 $1500.00 fine assessed