Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00260497-AP-215680
Provider Information
Klamath Falls Senior Living
2130 N ELDORADO AVE
Klamath Falls, OR 97601
- Provider ID
- 70M024
- Administrator
- Eileen McCoy
- Phone
- (541) 882-4830
- ed.klamathfalls@klamathfallsseniorliving.com
Violation Details
- Date
- 4/26/2023
- Report number
- 00260497-AP-215680
- Type
- Abuse: Neglect
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- 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: 411-054-0040(1)(b) and (c)
External site: 411-054-0045(1)(f)
- Findings
- On or about mid-afternoon on April 26, 2023, the Alleged Victim (AV) experienced a significant change of condition, exhibiting stoke like symptoms and high blood pressure readings. Facility staff recognized the change of condition and alerted AP2, but did not otherwise take appropriate immediate action. AP2 either did not assess AV or did not perform an adequate assessment in response. AV remained at the facility and continued to exhibit the same symptoms overnight until the facility sent the resident to the hospital the next morning, when it was discovered that the resident had suffered a stroke. The facility failed to provide training or tools for staff to recognize and respond appropriately to medical emergencies related to AV’s symptoms. AP2 was notified of AV’s significant change of condition and failed to properly conduct an assessment according to facility policy and OAR 411-054-0045(1)(f). AP2 advised staff not to call for emergency services and to put AV back to bed. AP2 did not provide staff with instructions for care and/or monitoring AV’s symptoms. The failure of the facility and AP2 to provide basic care and services necessary to maintain the health of safety of AV resulted in permanent loss to AV, physical harm, unreasonable discomfort, and delay that presented a serious risk of harm, which constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- ALFCP24-00667 $2500.00 fine assessed