OLRS 2008 Annual Report
Ombudsperson Section: Protection from Abuse and Neglect
OLRS' non-legal Ombudsperson Section was created by state law and is sustained by state General Revenue Funds. The Ombudsperson Section investigates complaints regarding health and safety, abuse and neglect and rights violations. Complaints are resolved through mechanisms such as mediation and negotiation.
In Fiscal Year 2008, the Ombudsperson Section continued investigations of children and adults who died in facilities, complained about conditions in nursing homes and other places, were abused and neglected in schools and institutions or were victims of theft.
Abuse and Neglect Investigations
The Ombudsperson Section issued reports to resolve abuse, neglect and conditions regarding a behavior modification program operating as a boot camp, and two children's residential treatment facilities. The reports included documentation of problems with licensure, restraint and other abuse, and failure to guarantee children the right to participate in an appropriate educational program.
Ombudsperson staff investigated a complaint that a school restrained a seven-year-old with a "humane body wrap" and placed the child in a locked basement room for several hours. OLRS' investigation revealed that the room and mechanical restraints had been used with students, and staff were not trained to use positive behavioral interventions. The school discontinued the use of the room and mechanical restraints, and trained staff to use positive behavioral supports. Since the Ohio Department of Education (ODE) provides no guidance or administrative oversight on this serious matter, OLRS recommended that ODE enact administrative rules on the use of emergency behavioral interventions before more children are injured, traumatized or die in Ohio's schools.
Death Investigations
An investigation into the death of a resident prompted the Ohio Department of Mental Retardation and Developmental Disabilities (ODMRDD) to resume the licensure revocation process for an intermediate care facility for the mentally retarded (ICF/MR). The facility has a history of citations from the Ohio Department of Health (ODH) and ODMRDD covering medical, program and environmental issues.
The Ombudsperson Section issued a formal report in response to the death of a resident who died of a perforated bowel. The investigation found a pattern of inadequate care and the report recommended ODMRDD revoke the facility's license to operate, place monitors in the facility, conduct a facility survey and impose other sanctions as appropriate. The report also included recommendations to other agencies responsible for oversight of the facility.
OLRS provided ODMRDD with information gathered from on-site monitoring and on-going review of facility records, major unusual incident reports and licensure surveys. OLRS identified problems for ODMRDD and ODH to look for during their surveys of the facility.
The Ombudsperson section report also recommended that ODH and ODMRDD conduct investigations of the death, and that ODMRDD review current care and services provided to all residents. Both state agencies responded with investigations.
Nursing Home Investigations
As in past years, the Ombudsperson Section has responded to complaints from residents housed in nursing home behavioral units. Ombudsperson section reports were issued to facilities, ODH and the Ohio Department of Job and Family Services (ODJFS). In its reports, OLRS advocated for the completion of resident reviews to determine the need for specialized services and for referrals to local mental health and MRDD boards for evaluation of services. Ombudsperson section staff also met with representatives of ODH and ODJFS in an attempt to resolve the issues, including the placement of younger people with disabilities on behavioral units, length of stay, lack of Preadmission Screening and Resident Reviews (PASRR), locked units and the completion of quality assurance/utilization reviews.
Theft Investigations
Ombudsperson section staff assured that money was restored to individuals that had been stolen by an employee entrusted with managing funds and other property of the group home they lived in. The investigation revealed that nearly $25,000 had been misappropriated. Following the investigation, the provider repaid the full amount owed to the individuals, developed a staff training and significantly improved procedures to ward off future theft. The staff person responsible for the theft was criminally charged.
