| 340:110-3-154.2(d) | Physical restraint. Restraint may only be used when less restrictive interventions, according to facility policy, have been attempted or when an immediate intervention is required to protect the resident, a staff member, or others. The restraint technique used must be the least restrictive intervention that will be effective to protect the resident or others from harm. Restraint must be discontinued at the earliest possible time. A written incident report is completed within 24-hours following each use of physical restraint. | Behavior Management: Staff used improper restraint techniques, causing significant bruising to a resident. | Program submitted plan of correction that included the following actions: (1) Staff members directly involved in the physical intervention were terminated; (2) All staff identified in the OC]A, report were debriefed, formally addressed, and expectations were reinforced; (3) All direct care staff completed refresher training on approved behavior management de-escalation practices, and physical intervention protocols; (4) Leadership increased routine oversight, increased weekly leadership meetings to discuss any
incidents and debrief them; (5) A leadership team meeting was held to reiterate Empact's zero-tolerance expectations
regarding improper restraints, failure to intervene, and deviations from approved practices. | Substantiated |
| 340:110-3-153.1(b) | Personnel and responsibilities. The program recruits personnel with specialized skills, knowledge, and the cultural understanding and competencies necessary for quality residential care services. Personnel demonstrate responsible behavior reasonably ensuring residents' care and safety. Personnel cooperate with Oklahoma Human Services (OKDHS) staff, including monitoring visits and investigations. | Additional Non-Compliance Found During Investigation: Personnel: Staff member responsible for behavior management training did not intervene as other staff members were improperly restraining resident. | Program submitted plan of correction that included the following action: Staff member continued to be monitored closely by the Specialized Placements and Partnership Unit (SPPU), with weekly contact and quarterly safety reviews. | Determined During Course of Investigation |
| 340:110-3-154.2(b)(1) | behaviors that could cause physical pain, such as shaking, striking, spanking, grabbing, yanking, pulling, pushing, choking, threatening, or other cruel treatment; | Additional Non-Compliance Found During Investigation: Behavior Management: Staff members used excessive force and prohibited behavior management actions in dealing with a resident's behaviors. | Program submitted plan of correction that included the following actions: (1) Staff members directly involved in the physical intervention were terminated; (2) All staff identified in the OC]A, report were debriefed, formally addressed, and expectations were reinforced; (3) All direct care staff completed refresher training on approved behavior management de-escalation practices, and physical intervention protocols; (4) Leadership increased routine oversight, increased weekly leadership meetings to discuss any incidents and debrief them; (5) A leadership team meeting was held to reiterate Empact's zero-tolerance expectations regarding improper restraints, failure to intervene, and deviations from approved practices. | Determined During Course of Investigation |