Failure to Report Alleged Abuse Involving Use of Physical Restraint
Penalty
Summary
The facility failed to notify the State Agency of an allegation of abuse involving a resident with diagnoses including Type II Diabetes, morbid obesity, bipolar disorder, and depression. The incident involved the use of a bath sheet held across the resident's torso and chest by staff to prevent the resident from harming others during a behavioral episode. Multiple staff interviews confirmed that the sheet was held by hand and not tied, and was used until police and EMS arrived. There was no physician order for a restraint, and the resident's medical record did not document any incident of restraint. The internal investigation by the Regional Administrator determined that the resident was not restrained, and as a result, the incident was not reported to the Ohio Department of Health as potential abuse. Facility policy requires immediate reporting of all allegations of abuse, neglect, or exploitation to the Administrator and the State Agency. The policy also defines abuse as the willful infliction of injury or unreasonable confinement, and specifies that a restraint is any device that a resident cannot remove and that restricts movement. Despite these policies, the facility did not report the incident as required, even though the use of the sheet could be considered a restraint and an allegation of abuse. This deficiency was substantiated during the survey and recited from a previous complaint survey.