Prior Facility History No prior reports or referrals Prior reports resource linked Prior substantiated referral/s Prior unsubstantiated referral/s Notes Risk Factors Protective Factors Chemical/physical restraint used without physician’s Appropriate SCM or other physical restraint used order Adequate staffing pattern to meet resident’s needs Inadequate training for direct care staff Chemical/physical restraint used with physician’s Inappropriate SCM or other physical restraint used order Insufficient staffing pattern to meet resident’s needs De-escalation techniques used prior to restraint No de-escalation techniques used prior to restraint Direct care staff appropriately trained No or inadequate staff policies Physician orders implemented Physician orders not implemented Staffed have been trained on facility policies Prescribed medications administer inaccurately System Failures led to abuse/neglect
Prior Facility History No prior reports or referrals Prior reports resource linked Prior substantiated referral/s Prior unsubstantiated referral/s Notes Risk Factors Chemical/physical restraint used without physician’s order Inadequate training for direct care staff Inappropriate SCM or other physical restraint used Insufficient staffing pattern to meet resident’s needs No de-escalation techniques used prior to restraint No or inadequate staff policies Physician orders not implemented Prescribed medications administer inaccurately System Failures led to abuse/neglect Protective Factors Appropriate SCM or other physical restraint used Adequate staffing pattern to meet resident’s needs Chemical/physical restraint used with physician’s order De-escalation techniques used prior to restraint Direct care staff appropriately trained Physician orders implemented Staffed have been trained on facility policies
ADT%20Facility%20Investigative%20Assessment-CPS.docx