Print Violation: 00308373-AP-261121

Provider Information

Crystal Terrace

1000 TOWN CENTER DRIVE
Klamath Falls, OR 97601

Date: 1/13/2024
Report number: 00308373-AP-261121
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to properly plan care
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings: The Alleged Victim (AV) had a history of falling out of bed. AV was care planned to have a wedge and a call system in place to assist with safety. On or about January 13, 2024, AV was experiencing more anxiety than usual and was trying to get out of bed. AV is prescribed an as needed anxiety medication. On that same evening, AV was found on the floor in his/her room, it is assumed AV fell from bed. AV was given his/her anxiety medication after the fall instead of earlier in the evening when he/she was experiencing the anxiety. AV's care plan does not address AV's anxiety and agitation. If the care plan had noted it, it may have lead staff to ensure AV received the anxiety medication earlier. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: RCFCP24-00607 $500.00 fine assessed