Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00248270-AP-204202
Provider Information
McMinnville Memory Care
320 SW HILL ROAD
Mcminnville, OR 97128
- Provider ID
- 5MA170
- Administrator
- Megan Wolfe
- Phone
- (503) 472-3509
- ed@mcminnvillememorycare.com
Violation Details
- Date
- 2/17/2023
- Report number
- 00248270-AP-204202
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0040(1)(b) and (c)
- Findings
- On or about February 17, 2023, the Alleged Victim (AV) fell from his/her wheelchair while left unattended in the facility’s communal room. AV had been moved to that area by staff during dining room cleaning. While unsupervised, AV fell from the wheelchair and struck his/her head on the floor, resulting in a laceration under the right eye, a rug burn on the right side of the forehead, and a cervical fracture. AV was transported to the emergency department for evaluation and treatment. AV passed away on February 20, 2023. Facility documentation and interviews show that between August 19, 2022, and February 17, 2023, a period of seven months, AV experienced fourteen falls. These repeated falls caused multiple injuries, including rug burns, skin tears, and reported pain involving the head, shoulders, and arms. Documentation further indicates that AV slipped from the wheelchair on at least six occasions during this period. Although staff discussed possible fall-prevention interventions, such as using a lap buddy or a specialized wheelchair, there was no documented evidence that these were implemented. The facility failed to put effective interventions in place to prevent AV from repeatedly sliding or falling from the wheelchair which contributed to AV’s fall on February 17, 2023, that resulted in serious injuries which is a violation of resident rights, is considered neglect of care which constitutes abuse.
- Sanction
- RCFCP26-00237 $1500.00 fine assessed