Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00357660-AP-308152
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
- 6/25/2024
- Report number
- 00357660-AP-308152
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- 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)(H) and (I)
External site: 411-054-0036(2)(g)
External site: 411-054-0070(1)
- Findings
- Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met. AV service plan dated on or about May 21, 2024, indicates AV is independent with ambulation and transfers, independent using a walker, and requires staff to provide assistance each shift with toileting and as needed or requested by AV. AV often wakes in the night to use the restroom. AV is able to use h/h call light independently. Fall interventions in place, ensure AV is using h/h walker, safety checks three times per shift, sign placed in AV’s room reminding AV to sit before putting h/h shoes on, remind AV to call for assistance, and a bed cane will be placed near AV's bed, check at routine intervals at night without waking. AV experienced an unwitnessed fall on or about May 29, 2024, two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) and diagnosed with a contusion to h/h forehead . AV experienced an unwitnessed fall on or about June 19, 2024, when AV was found on the flour attempting to ask for help. AV experienced two more falls on or about June 20, 2024, sustaining bruising to h/h upper back in the first fall and a lump to h/h head in the second fall. AV was transported to the ER and diagnosed with a scalp hematoma. AV experienced unwitnessed falls on or about June 23 & 24, 2024, both noted to be non-injury falls. The fall interventions implemented following these falls were to request a referral for physical and occupational therapy, request a medication review, add a high protein snack before bed, and decrease AV's sleep medication; these interventions were not documented until June 25, 2024. On June 25, 2024, approximately less than four hours after AV's fall on June 24, 2024, AV experienced an unwitnessed fall in h/h room and complained of pain to h/h head, shoulders, leg, and arm. AV was transported to the ER where s/he was diagnosed with a head contusion and found to have bruising and scrapes. AV experienced nine documented unwitnessed falls in under a month; the fall prevention interventions implemented by the facility prior to AV's fall on June 25, 2024, were already in AV's May 21, 2024, service plan or failed to be reasonably be person centered interventions to address Av's increased and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00256 $1000.00 fine assessed