Print Violation: 00349635-AP-300013

Provider Information

Guardian Angel Homes

540 NW 12TH ST
Hermiston, OR 97838

Date: 8/20/2024
Report number: 00349635-AP-300013
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)
Findings: The Alleged Victim (AV) relies on the facility for care and is care planned to have a bed alarm in place due to being a fall risk. According to an investigation, on or about August 20, 2024, the Alleged Perpetrator 2 (AP2), provided assistance to AV, and then helped AV back into bed. Approximately 30 minutes later AV was found on the floor after a fall. AV's bed alarm was not going off and it was discovered that AP2 did not turn AV's bed alarm back on after providing initial care, and therefore staff were not alerted that AV had gotten up, resulting in a fall with a fracture. 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.