Print Violation: 00379972-AP-330463

Provider Information

Footsteps at Mill Creek

1201 W 10TH STREET
The Dalles, OR 97058

Date: 1/27/2025
Report number: 00379972-AP-330463
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious 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)
Findings: According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the care plan for the Alleged Victim (AV) by utilizing a two-person transfer. On or about January 25, 2025, Ap2 attempted to self transfer the AV. The AV’s care plan was updated on or about December 23, 2024, to use two persons for assist for the AV. In an interview with the AP2, AP2 admitted they were unaware the AV was a 2-person transfer. During the self-transfer, the AV suffered a fall and sustained a laceration on their leg which required stitches. The failure to follow the care plan caused the AV to fall, leading to an injury which required medical attention and stitches, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.