Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00282396-AP-236840
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
- 8/25/2023
- Report number
- 00282396-AP-236840
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0025(1)(a)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0040(1)(a), (d)(A and B)
- Findings
- Alleged Victim Admit into the facility on or about February 21, 2023. AV has a history of six falls from February 21, 2023, to August 25, 2023. AV has a diagnosis of dementia and vertigo, uses a walker/wheelchair to ambulate and is a one person assist with transfers to and from wheelchair. AV fell out of bed on or about August 1, 2023, was found on the floor, sent to the hospital, and diagnosed with a hip fracture. Between August 1, 2023, and August 25, 2023, AV repeatedly attempts to get out of bed experiences hallucinations and increased confusion. Per AVs service plan the only intervention the facility had in place were safety checks with no specific instruction for the intent of the safety checks. No other instructions were provided to staff. On August 25, 2023, AV was found on the floor of their apartment with h/h left arm and knuckles bleeding. AV stated they hit their head on the floor. Staff reported, it looks like AV had been trying to get out of bed. AV was sent to the ED. As a result of the fall on August 25, 2023, AV suffered a blow to their head complained of head pain and required seven (7) stiches in h/h left arm. The facility failed to intervene when the Alleged Victim ‘s (AV) condition changed, failed to appropriately care plan, and implement reasonable resident specific interventions to address AV’s ongoing falls, repeated attempts to get out of bed which led to falls and address the hallucinations and increased confusion and communicate interventions to staff, which is violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP24-00541 $375.00 fine assessed