Print Violation: 00238221-AP-195354

Provider Information

Bonaventure of Tigard Memory Care

15000 SW HALL BLVD
Tigard, OR 97224

Date: 12/20/2022
Report number: 00238221-AP-195354
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious 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) is care planned to be a 2-person assist for ambulating/transfers. On or about December 20, 2022, Alleged Perpetrator 2 (AP2) was wheeling AV from the bathroom to bed when AV tripped over the front of the wheelchair, fell, and landed on their face. As a result, AV suffered a broken nose as well as bruising on other parts of their face. AP2 had failed to properly use the wheelchair feet supports while wheeling AV. AP2 was aware that AV was a 2-person assist and decided to ambulate AV by themselves. On or about December 23, 2022, the facility failed to provide adequate staffing to meet AV’s service plan requirements, leading to AV falling once again. The facility failed to assure AV’s care plan was being followed, leading to AV sustaining a fracture nose, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: RCFCP23-01503 $1500.00 fine assessed