Failure to Report Alleged Abuse Involving Physical Restraint
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by policy and regulation. A resident with dementia, agitation, anxiety, and psychotic disorder with hallucination was found physically restrained in her wheelchair with a gait belt wrapped around the wheelchair arms to prevent her from standing or falling. This action was taken by a CNA after the resident was observed to be restless, hallucinating, combative, and attempting to get out of bed and walk. The restraint was discovered by staff at the start of the first shift, and the gait belt was immediately removed. The resident's family and Medical Director were notified, and a psychosocial assessment was completed with no concerns noted. Despite the incident meeting the facility's policy definition of abuse as an act of unreasonable confinement, the event was not reported to the Ohio Department of Health as an allegation of abuse. The Administrator confirmed that an internal investigation was conducted and the staff member involved was suspended during the investigation, but the incident was not reported externally because the Administrator did not believe the action was intended to be abusive and the resident was not harmed. Review of the facility's Self-Reported Incidents (SRI) confirmed that no report was made to the State Survey Agency regarding this incident.