Who authorized/approved restraint (longer than 30 minutes) __________________________________ Was injury to the client? Yes or No Did the client require treatment? Yes or No Was there injury to staff? Yes or No Did staff require treatment? Yes or No Rights Violation Summary of How were the youth’s rights violated? Response: Describe provider response to situation? Debriefing with youth? Guardian notified/involved? Type of Rights Violations Religious Practice (Check all that apply) □ Behavior modifications Medical Care Social Activity □ □ □ Communication Nutrition Voting (18-21 yo) □ □ □ Confidentiality (HIPPA) Physical Restraint Work □ □ □ Discipline Personal property Record □ □ □ Humane Treatment Physical Exercise Seclusion □ □ □ Serious Injury to Client Summary of Describe any harm that required emergency services (key words are services”). “emergency Describe type of injury and what caused injury. Only report events that occur during the provision of services. Response: Describe provider response to situation. What treatment was received and Type of injury: Cause of Injury: Lacerations requiring stitched/staples Fall Origin unknown □ □ □ Bone Accident Quality of care □ □ □ Joint dislocation Seizure Near drowning □ □ □ Head injury Medical ________________ □ □ Serious burn Condition □ Skin wound Treatment error □ □ Other _____________________ did person receive treatment: ER Intervention on site Urgent Care □ □ □ Admitted to hospital Primary Care Other: __________________ □ □ Suicide
Who authorized/approved restraint (longer than 30 minutes) __________________________________ Was injury to the client? Yes or No Did the client require treatment? Yes or No Was there injury to staff? Yes or No Did staff require treatment? Yes or No Rights Violation Summary of How were the youth’s rights violated? Response: Describe provider response to situation? Debriefing with youth? Guardian notified/involved? Type of Rights Violations (Check all that apply) □ Behavior modifications □ Communication □ Confidentiality (HIPPA) □ Discipline □ Humane Treatment □ Medical Care □ Nutrition □ Physical Restraint □ Personal property □ Physical Exercise □ Religious Practice □ Social Activity □ Voting (18-21 yo) □ Work □ Record □ Seclusion Serious Injury to Client Summary of Describe any harm that required emergency services (key words are “emergency services”). Describe type of injury and what caused injury. Only report events that occur during the provision of services. Response: Describe provider response to situation. What treatment was received and Type of injury: □ Lacerations requiring stitched/staples □ Bone □ Joint dislocation □ Head injury □ Serious burn □ Skin wound Other _____________________ Cause of Injury: □ Fall □ Accident □ Seizure □ Medical Condition □ Treatment error □ Origin unknown □ Quality of care □ Near drowning ________________ did person receive treatment: □ ER □ Admitted to hospital □ Intervention on site □ Primary Care □ Urgent Care Other: __________________ Suicide
OCFS%20Reportable%20Events%20Form%205-14-18.docx