Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00345459-AP-295970
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
- 7/27/2024
- Report number
- 00345459-AP-295970
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- 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: 411-054-0030(1)(e)(A) and (H)
External site: 411-054-0036(2)(g)
- Findings
- Alleged Victim (AV) Service Plan dated on or about July 2, 2024 indicates AV is to receive safety checks twice per night, AV is able to get in and out of bed, chair, car, without assistance, AV may require occasional assistance with transfers and will ask staff when needed. AV is independent with ambulation and, uses a walker. As a fall prevention intervention AV requires a pressure alarm be under h/h anytime AV is seated or in bed. On or about July 27, 2024, AV experienced a fall while s/he was ambulating without an assistive device and fell prior to reaching the intended chair. On or about July 29, 2024, AV had an unwitnessed fall in h/h room and sustained an abrasion to h/h head; AV was transported to the Emergency Department for evaluation. After returning from the ED on July 30, 2024, staff found AV on the floor of h/h room and AV was transported back to the ED. AV returned back on July 30, 2024 to have AV's bed alarm sound and AV found on the floor in h/h room. Temporary Service Plans provided by the facility did not provide updated transfer, ambulation, or fall prevention intervention instructions for staff until after AV's fourth fall in several days; the TSPs provide information on monitoring AV for latent injury and not fall interventions. Following AV's fourth fall, a TSP was implemented instructing staff to provide AV with frequent safety checks, monitor AV for attempts to self-transfer, and use a fall mat next to AV's bed. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00172 $450.00 fine assessed