Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00247831-AP-217948
Provider Information
Mountain Park Memory Care Community
13600 SE 122ND AVE
Clackamas, OR 97015
- Provider ID
- 50R483
- Administrator
- AMY BUCHANAN
- Phone
- (503) 919-7722
- ed@mountainparkmc.com
Violation Details
- Date
- 2/18/2023
- Report number
- 00247831-AP-217948
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- 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: 411-054-0030(1)(e)(F)
External site: 411-054-0070(1)(b)
- Findings
- Alleged Victim's (AV's) service plan for Dietary/Eating dated on or about February 6, 2023, notes instructions: Regular, Physical assistance, Hand under hand. AV is on Regular diet and regular texture foods, s/he is also on thin liquids. AV requires staff assistance with eating, staff to offer physical eating assist at all meals. AV is often using staff assist for eating. Interim service plan for Weight loss and assistance with eating dated on or about June 24, 2021, use hand under hand technique, Encourage fluids between every few bites. On or about February 18, 2023, around 12:30 PM, Alleged Perpetrator 2 (AP2) was feeding AV when AV choked on food. As a result of the choking the food was not successfully dislodged and AV was pronounced deceased by EMS. Per Facility Protocol: Conscious Choking (Cannot Cough, Speak, Cry or Breathe) instructions; 1) Give 5 back blows. 2) Give abdominal thrusts. 3) Repeat 1 and 2 until: object is forced out; person can cough forcefully or breathe, or person becomes unconsciousness. If person becomes unconscious, carefully lower person to ground and give care of unconscious choking, beginning, and looking for an object. Per the training staff are supposed to complete the Heimlich Maneuver if a resident chokes. The facility video recording shows the first three staff not completing the Heimlich maneuver. The facility failed to provide a safe environment, the licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Which is violation of resident’s rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00462 $2500.00 fine assessed