Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00327291-AP-278743
Provider Information
Bridgecreek Memory Care
1401 S 12TH STREET
Lebanon, OR 97355
- Provider ID
- 50A253
- Administrator
- Jennifer Parker
- Phone
- (541) 259-1779
- jparker@sapphirehealthservices.com
Violation Details
- Date
- 4/25/2024
- Report number
- 00327291-AP-278743
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to follow care plan
- 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)
- Findings
- Alleged Victim (AV) requires maximum assistance with all personal care and activities of daily living. AV has an extensive fall history and requires an intervention of a fall buddy on AV's wheelchair to mitigate the risk of falls. Lap buddy intervention was put into effect on April 2, 2024. On or about April 25, 2024, AV was found on the floor in front of AV’s wheelchair, on AV’s right side leaning on AV’s right elbow. AV was singing and not in distress. AV’s alarm was on and working. AV’s lap buddy was not in use. AV’s fall was unwitnessed. AP2 was assigned to AV and forgot to place lap buddy with AV. AV was assessed for injuries with findings of a small skin abrasion on the right elbow with no other injuries noted. AP2 admits the wrongdoing of forgetting to put the lap buddy on AV's wheelchair leading to AV having a fall on AP2 admits the wrongdoing of forgetting to put the lap buddy on AV's wheelchair leading to AV having a fall on 04/25/2024. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.