Category 2 physical abuse/restraint, Category 3 neglect found. Subject in OCFS facility found to have used unwarranted restraint with unauthorized technique and unreasonable force.

Category 3 obstruction found. Subject failed to report inappropriate mealtime restraint of Service Recipient to VPCR after learning of incident from parents.

Category 3 psychological abuse not found. Subject found not aware of policy for cleaning hoarding Service Recipient’s room while Service Recipient away.

Category 3 abuse (deliberate inappropriate use of restraints) found. Subject found to have used improper technique during restraint by crossing/holding the Service Recipient’s legs.

Category 3 neglect found. Subject (RN) breached a duty by failing to properly conduct a post restraint visual health assessment of a Service Recipient.

Category 3 obstruction found. Subject failed to make VCPR report after witnessing other staff’s unauthorized conduct toward a Service Recipient.

Category 3 neglect found. Subject failed to deescalate, encouraged fight between service recipients and directed threatening/derogatory language toward the Service Recipient.

Category 3 neglect found. Subject left Service Recipient alone in van for seventeen minutes while she asked for directions.

Category 3 neglect found. Subject breached her duty by leaving the facility knowing that the facility would be understaffed.

Category 3 neglect found. Subject failed to follow Service Recipient’s plans by leaving Service Recipient alone in bedroom when engaging in self-injurious behavior.