Failure to Timely Report and Document Manual Hold Incident
Penalty
Summary
The provider failed to follow its policy requiring an initial report to the South Dakota Department of Health (SD DOH) within two hours of an incident involving a resident who experienced a behavioral event necessitating a manual hold by staff. On the evening of the incident, the resident became upset near an exit door, struck out at a mental health aide, and was subsequently placed in a low-level manual hold by two aides, which was later transitioned to a medium-level hold and then back to a low-level hold as the resident was assisted to the dining area. The manual hold ended after several minutes, but the nurse on duty did not notify the required individuals or document the use of the manual hold at that time. Additionally, the nurse did not assess the resident or perform any nursing duties associated with the use of the manual hold. The initial and final report of the incident was not filed with the SD DOH until nearly two days later, well beyond the two-hour reporting requirement outlined in the facility's Prevention of Mistreatment, Exploitation, Neglect and Abuse policy. Interviews with staff and the DON confirmed that the reporting and documentation procedures were not followed, and the required assessment and notifications were not completed. The DON also confirmed that the policy was not adhered to in this instance.