Category 3 neglect not found. It was not established that Subject turned her back when distributing medication to the Service Recipient.

Category 4 neglect found when facility exposed Service Recipient to harm by failing to have a visitor policy or procedure.

Category 3 deliberate inappropriate use of restraints found for escorting/restraining Service Recipient not in accord with policy.

Category 3 abuse found. Subject inappropriately ordered a restraint by use of an intramuscular injection of psychiatric medication. Pre-requisite for restraint not met.

Neglect not found. Subject did not have a duty due to systemic issues at facility.

Category 3 neglect unsubstantiated as Subject made a decision in an emergency situation with no lasting negative consequences.

Category 4 neglect unsubstantiated. Lack of evidence of harm or risk of harm mitigated by systemic problems such as inadequate management, staffing, training, or supervision.

Category 4 neglect found when facility exposed service recipients to harm through systemic problems of inadequate management, staffing, training, and supervision.