Category 3 neglect found.  Subject failed to take the Service Recipient to the hospital as directed.

When Subject returned to work, she had reasonable cause to suspect that Service Recipient’s injury was a significant incident. Had duty to report.

Video shows Subject restraint deliberately inconsistent with PMCS, failure to deescalate a breach. Subject physical contact was reckless.

Category 3 abuse, deliberate inappropriate use of restraints found. Subject restrained Service Recipient with excessive force, improperly holding Service Recipient's arms behind his head.

Category 3 neglect found.  Subject breached her duty by failing to ensure adequate staffing levels.

Category 3 neglect found.  Subject less than alert while on duty.

Subject RN breached duty to observe Service Recipient at all times and Service Recipient had sexual encounters with another Service Recipient.

Category 2 neglect and Category 2 abuse (obstruction of reports of reportable incidents) both substantiated, reduced to Category 3, failed to show serious endangerment.

Category 3 neglect found. Subject breached duty to record/report low blood glucose level, call RN and call 911.

Category 3 restraint not found. Subject’s use of improper technique found to be reasonable emergency intervention necessary to prevent risk of harm to others.