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Lawriter - OAC - 5122-14-14 Incident notification and risk management.

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http://codes.ohio.gov/oac/5122-14-14

5122-14-14 Incident notification and risk management.
(A) This rule establishes standards to ensure the prompt and accurate notification of certain prescribed
incidents. It also requires the agency to review and analyze all incidents so that it might identify and
implement corrective measures designed to prevent recurrence and manage risk.
(B) Definitions
(1) “Incident” means an event that poses a danger to the health and safety of patients and/or staff and
visitors of the hospital, and is not consistent with routine care of persons served or routine operation of the
hospital.
(2) “Reportable incident” means an incident that must be submitted to the department, including incidents
that must then be forwarded by the department to the Ohio legal rights service pursuant to section 5123.604
of the Revised Code. As referenced in division (C) of section 5119.611 of the Revised Code, “major unusual
incident” has the same meaning as “reportable incident.”
(3) “Six month reportable incident” means an incident type of which limited information must be reported to
the department. A six month reportable incident is not the same as a reportable incident.
(4) “Six month incident data report” means a data report which must be submitted to the department.
(C) The inpatient psychiatric service provider shall develop an incident reporting system to include a
mechanism for the review and analysis of all reportable incidents such that clinical and administrative
activities are undertaken to identify, evaluate, and reduce risk to patients, staff, and visitors. The inpatient
psychiatric service provider shall identify in policy other incidents to be reviewed and analyzed.
(1) An incident report shall be submitted in written form to the inpatient psychiatric service provider’s chief
executive officer or designee within twenty-four hours of discovery of the incident.
(2) As part of the inpatient psychiatric service provider’s performance improvement process, a periodic review
and analysis of reportable incidents, and other incidents as defined in policy, shall be performed.
(3) The inpatient psychiatric service provider shall maintain an ongoing log of its reportable incidents for
departmental review.
(D) Any person who has knowledge of any instance of abuse or neglect, or alleged or suspected abuse or
neglect, or of an alleged crime which would constitute a felony, of:
(1) Any child or adolescent, shall immediately notify any alleged or suspected abuse or neglect to the county
children’s services board, the designated child protective agency, or law enforcement authorities, in
accordance with section 2151.421 of the Revised Code, or of an alleged crime against a child or adolescent
which would constitute a felony, including a crime allegedly committed by another child or adolescent which
would constitute a felony if committed by an adult, shall immediately notify law enforcement authorities.
(2) An elderly person, shall immediately notify the appropriate law enforcement and county department of
jobs and family services authorities in accordance with section 5101.61 of the Revised Code.
(E) Each inpatient psychiatric service provider shall submit reportable incidents and six month reportable
incidents as defined by and according to the schedule included in appendix A to the rule.
(F) Each reportable incident shall be documented on form “DMH-LIC-013” as required by the department, and
shall be forwarded to the department within twenty-four hours of its discovery, exclusive of weekends and
holidays. Form “DMH-LIC-013” shall include identifying information about the inpatient psychiatric service

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Lawriter - OAC - 5122-14-14 Incident notification and risk management.

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http://codes.ohio.gov/oac/5122-14-14

provider, date, time and type of incident, and client information that has been de-identified pursuant to the
HIPAA privacy regulations, [ 45 C.F.R.164.514(b)(2) ].
(1) The inpatient psychiatric service provider shall file only one incident form per event occurrence and
identify each incident report category, if more than one, and include information regarding all involved
patients, staff, and visitors.
(2) The inpatient psychiatric service provider shall notify the patient’s parent, guardian or custodian, if
applicable, within twenty-four hours of discovery of a reportable incident, and document such notification.
(a) Notification may be made by phone, mailing, faxing or e-mailing a copy of the incident form, or other
means according to inpatient psychiatric service provider policy and procedures.
(b) When notification does not include sending a copy of the incident form, the inpatient psychiatric service
provider must inform the parent, guardian or custodian, of his/her right to receive a copy, and forward a copy
within twenty-four hours of receiving a request for a copy. The inpatient psychiatric service provider shall
document compliance with the provisions of this paragraph.
(G) Each inpatient psychiatric service provider shall submit a six month incident data report to the
department utilizing the form that is in appendix B to this rule.
The six month data report must be submitted according to the following schedule:
(1) The six month data report for the period of January first to June thirtieth of each year shall be submitted
no later than July thirty-first of the same year; and
(2) The six month data report for the period of July first to December thirty-first of each year shall be
submitted no later than January thirty-first of the following year.
(H) The department may initiate follow-up and further investigation of a reportable incident and six month
reportable incidents, as deemed necessary and appropriate, or may request such follow-up and investigation
by the inpatient psychiatric service provider, and/or regulatory or enforcement authority.
Replaces: Part of 5122-14-10
Click to view Appendix
Click to view Appendix
Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5119.20
Rule Amplifies: 5119.20
Prior Effective Dates: 10/12/78, 1/1/91, 1/1/00, 11/01/05

1/31/2013 1:55 PM

ACTION: Final

ENACTED
5122-14-14

Appendix
Appendix A
5122-14-14

DATE: 09/08/2011 12:39 PM

Inpatient Psychiatric Service Provider
Reportable and Six Month Reportable Incidents

In addition to the definitions in rule 5122-14-01 and of the Administrative Code, the following definitions are
applicable to Ohio Administrative Code (OAC) rule 5122-14-14 “Incident Notification and Risk Management”:
(1) "Emergency/Unplanned Medical Intervention" means treatment required to be performed by a licensed medical
doctor, osteopath, podiatrist, dentist, physician's assistant, or certified nurse practitioner, but the treatment
required is not serious enough to warrant or require hospitalization. It includes sutures, staples,
immobilization devices and other treatments not listed under "First Aid", regardless of whether the treatment
is provided in the hospital, or at a doctor's office/clinic/hospital ER, etc. This does not include routine medical
care or shots/immunizations, as well as diagnostic tests, such as laboratory work, x-rays, scans, etc., if no
medical treatment is provided.
(2) "First Aid" means treatment for an injury such as cleaning of an abrasion/wound with or without the application
of a Band-aid, application of a butterfly bandages/Steri-Strips™, application of an ice/heat pack for a bruise,
application of a finger guard, non-rigid support such as a soft wrap or elastic bandage, drilling a nail or
draining a blister, removal of a splinter, removal of a foreign body from the eye using only irrigation or swab,
massage, drinking fluids for relief of heat stress, eye patch, and use of over-the-counter medications such as
antibiotic creams, aspirin and acetaminophen. These treatments are considered first aid, even if applied by a
physician. These treatments are not considered first aid if provided at the request of the patient and/or to
provide comfort without a corresponding injury.
(3) "Hospitalization" means inpatient treatment provided at a medical acute care hospital, regardless of the length
of stay. Hospitalization does not include treatment when the individual is treated in and triaged through the
emergency room with a discharge disposition to return to the community, or admission to a psychiatric unit.
(4) "Injury" means an event requiring medical treatment that is not caused by a physical illness or medical
emergency. It does not include scrapes, cuts or bruises which do not require medical treatment.
(5) "Sexual Conduct" means as defined by Section 2907.01 of the Ohio Revised Code, vaginal intercourse between
a male and female; anal intercourse, fellatio, and cunnilingus between persons regardless of sex; and, without
privilege to do so, the insertion, however slight, of any part of the body or any instrument, apparatus, or other
object into the vaginal or anal opening of another. Penetration, however slight, is sufficient to complete
vaginal or anal intercourse.
(6) "Sexual Contact" means as defined by Section 2907.01 of the Ohio Revised Code, any touching of an
erogenous zone of another, including without limitation the thigh, genitals, buttock, pubic region, or, if the
person is a female, a breast, for the purpose of sexually arousing or gratifying either person.

APPENDIX p(70517) pa(145502) d(331918) ra(285711)

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 1 of 7

print date: 09/08/2011 9:06 PM

Reportable Incidents
The following lists and defines each event category which must be reported per incident in accordance with
paragraph (F) of rule 5122-14-14 of the Administrative Code.
Category

Reportable Incident Definition

Suicide

The intentional taking of one’s own life by a patient.

Suicide Attempt

Intentional action by a patient with the intent of taking one’s own life, and is
either a stated suicide attempt or clinically determined to be so, regardless of
whether it results in medical treatment.

Self-Injurious Behavior

Intentional injury caused by a patient to oneself that is neither a stated suicide
attempt, or clinically determined to be so, which requires emergency/unplanned
medical intervention or hospitalization, and which happens on the grounds of the
hospital or during the provisions of care or treatment, including during hospital
off-grounds events.

Homicide by Patient

The alleged unlawful killing of a human being by a patient.

Homicide of Patient

The alleged unlawful killing of a patient by another person.

Natural Death

Death of a patient without the aid of inducement of any intervening
instrumentality, i.e. homicide, suicide or accident

Accidental Death

Death of a patient resulting from an unusual and unexpected event that is not
suicide, homicide or natural, and which happens on the grounds of the hospital or
during the provisions of care or treatment, including during hospital off-grounds
events.

Verbal Abuse

Allegation of staff action directed toward a patient that includes humiliation,
harassment, and threats of punishment or deprivation.

Physical Abuse

Allegation of staff action directed toward a patient of hitting, slapping, pinching,
kicking, or controlling behavior through corporal punishment or any other form
of physical abuse as defined by applicable sections of the Revised or
Administrative Code.

Sexual Abuse

Allegation of staff action directed toward a patient where there is sexual contact
or sexual conduct with the patient, any act where staff cause one or more other
persons to have sexual contact or sexual conduct with the patient, or sexual
comments directed toward a patient. Sexual conduct and sexual contact have the
same meanings as in Section 2907.01 or the Revised Code.

Neglect

Allegation of a purposeful or negligent disregard of duty imposed on an
employee by statute, rule, organizational policy, or professional standard and
owed to a patient by that staff member.

Defraud

Allegation of staff action directed toward a patient to knowingly obtain by
deception or exploitation some benefit for oneself or another or to knowing
cause, by deception or exploitation, some detriment to another.
Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 2 of 7

Reportable Incidents
The following lists and defines each event category which must be reported per incident in accordance with
paragraph (F) of rule 5122-14-14 of the Administrative Code (continued).
Category

Reportable Incident Definition

Involuntary Termination
Without Appropriate
Patient Involvement

Discontinuing services to a patient without informing the patient in advance of
the termination, providing a reason for the termination, and offering a referral to
the patient. This does not include situations when a patient discontinues services
without notification, and the hospital documents it was unable to notify the
patient due to lack of address, returned mail, lack of or non-working phone
number, etc.

Sexual Assault by Nonstaff, Including a Visitor,
Patient or Other

Any allegation of one or more of the following sexual offenses as defined by
Chapter 2907 of the Revised Code committed by a non-staff against another
individual, including staff, and which happens on the grounds of the hospital or
during the provisions of care or treatment, including during hospital off-grounds
events: Rape, sexual battery, unlawful sexual conduct with a minor, gross sexual
imposition, or sexual imposition.

Physical Assault by Nonstaff, Including Visitor,
Patient or Other

Knowingly causing physical harm or recklessly causing serious physical harm to
another individual, including staff, by physical contact with that person, which
results in an injury requiring emergency/unplanned medical intervention or
hospitalization, and which happens on the grounds of the hospital or during the
provision of care or treatment, including during hospital off-grounds events.

Medication Error

Any preventable event while the medication was in the control of the health care
professional or patient, and which resulted in permanent patient harm, transfer to
a hospital medical unit, or death. Such events may be related to professional
practice, health care products, procedures, and systems, including prescribing;
order communication, product labeling, packaging, and nomenclature;
compounding; dispensing; distribution; administration; education; monitoring;
and use.

Adverse Drug Reaction

Unintended, undesirable or unexpected effect of a prescribed medication(s) that
resulted in permanent patient harm, transfer to a hospital medical unit, or death.

Patient Fall

Loss of upright position that results in landing on the floor, ground or an object or
furniture, or a sudden, uncontrolled, unintentional, non-purposeful, downward
displacement of the body to the floor/ground or hitting another object like a chair
or stair, resulting in:
1. No injury
2. Injury requiring first aid
3. Injury requiring emergency/unplanned medical intervention
4. Injury requiring hospitalization

Subcategory (check one)

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 3 of 7

Reportable Incidents
The following lists and defines each event category which must be reported per incident in accordance with
paragraph (F) of rule 5122-14-14 of the Administrative Code (continued).
Category

Reportable Incident Definition

Medical Events Impacting
Hospital Operations

The presence or exposure of a contagious or infectious medical illness within an
hospital, whether brought by staff, patient, visitor or unknown origin, that poses a
significant health risk to other staff or patients in the hospital, and that requires
special precautions impacting operations. Special precautions impacting
operations include medical testing of all individuals who may have been present
in the hospital, when isolation or quarantine is recommended or ordered by the
health department, police or other government entity with authority to do so,
and/or notification to individuals of potential exposure. Special precautions
impacting operations does not include general isolation precautions, i.e.
suggesting staff and/or patients avoid a sick individual or vice versa, or when a
disease may have been transmitted via consensual sexual contact or sexual
conduct.

Away Without Leave
(AWOL)

A patient in an acute inpatient setting has been absent from a location defined by
the patient's status regardless of leave or legal status. A patient is considered to be
AWOL if the patient (1) has not been accounted for when expected to be present,
or (2) has left the grounds of the hospital without permission. Implicit in this
definition is that the patient has been informed of the limits placed on his/her
location prior to the elopement incident.

Discharge to Homeless
Shelter

Discharge or relocation of a patient from an acute, inpatient setting to a homeless
shelter, unless it is the expressed wish of the patient, the responsible Board or
contract agency has been involved in the decision-making process, and other
placement options have been offered to the individual patient and have been
refused.

Discharge to Homeless Street

Discharge or relocation of a patient from an acute, inpatient setting who refuses
all aftercare placement options, including homeless shelters, offered by the
hospital, board and agency.

Temporary Relocation of
Patients
Subcategory (check one)

Some or all of the patients must be moved to another unit or hospital for a
minimum period of at least one night due to:
1. Fire
2. Disaster (flood, tornado, explosion, excluding snow/ice)
3. Failure/Malfunction (gas leak, power outage, equipment failure
4. Other (name)

Continued On Page 5 & 6 for Seclusion and Restraint & Use of Force Related Incidents

Continued On Page 7 for Six Month Reportable Incidents

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 4 of 7

Reportable Incidents
The following lists and defines each event category which must be reported per incident in accordance with
paragraph (F) of rule 5122-14-14 of the Administrative Code (continued).
Category

Reportable Incident Definition

Inappropriate Use of
Seclusion or Restraint

Seclusion or restraint utilization that is not clinically justified or employed
without the authorization of staff permitted to initiate/order mechanical seclusion
or restraint
1. Seclusion
2. Mechanical restraint
3. Physical restraint
4. Transitional hold
The total number of minutes of the seclusion or restraint.

Subcategory (check all that
apply)

Total Minutes
Inappropriate Restraint
Techniques and other Use
of Force
Subcategory (check all that
apply)

Staff utilize one or more of the following methods/interventions prohibited by
paragraph (D)(2) of rule 5122-26-16 of the Administrative Code:
1. Behavior management interventions that employ unpleasant or aversive
stimuli such as: the contingent loss of the regular meal, the contingent
loss of bed, and the contingent use of unpleasant substances or stimuli
such as bitter tastes, bad smells, splashing with cold water, and loud,
annoying noises
2. Any technique that restricts the patient’s ability to communicate
3. Any technique that obstructs vision
4. Any technique that obstructs the airways or impairs breathing
5. Weapons and law enforcement restraint devices, as defined by CMS in
appendix A of its interpretive guidelines to 42 C.F.R. 482.13(f) and found
in manual publication No. 100-7, "Medicare State Operations", used by
any hospital staff or hospital-employed security or law enforcement
personnel, as a means of subduing a patient to place that patient in patient
restraint/seclusion; or
6. Chemical restraint. A drug or medication administered involuntarily to an
individual in an emergency may be considered a chemical restraint if both
conditions cited in paragraph (C)(6) of rule 5122-14-01 of the
Administrative Code are met.

Seclusion/Restraint Related Injury to a patient caused, or it is reasonable to believe the injury was caused by
being placed in seclusion/restraint or while in seclusion/restraint, and first aid or
Injury to Patient
emergency/unplanned medical intervention was provided or should have been
provided to treat the injury, or medical hospitalization was required. It does not
include injuries which are self-inflicted, e.g. a patient banging his/her head,
unless the hospital determines that the seclusion/restraint was not properly
performed by staff, or injuries caused by another patient, e.g. a patient hitting
another patient.
Subcategory (check one)
1. Injury requiring first aid
2. Injury requiring unplanned/emergency medical intervention
3. Injury requiring hospitalization

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 5 of 7

Reportable Incidents
The following lists and defines each event category which must be reported per incident in accordance with
paragraph (F) of rule 5122-14-14 of the Administrative Code (continued).
Category

Reportable Incident Definition

Seclusion/Restraint Related Injury to staff caused, or it is reasonable to believe the injury was caused as a
result of placing an individual in seclusion/restraint, and first aid or
Injury to Staff
emergency/unplanned medical intervention was provided or should have been
provided to treat the injury, or medical hospitalization was required. It does not
include injuries which occur prior to, or are the rationale for, placing an
individual in seclusion or restraint.
Subcategory (check one)
1. Injury requiring first aid
2. Injury requiring emergency/unplanned medical intervention
3. Injury requiring hospitalization
Seclusion/Restraint Related Death of a patient which occurs while a patient is restrained or in seclusion,
within twenty-four hours after the patient is removed from seclusion or restraint,
Death
or it is reasonable to assume the patient’s death may be related to or is a result of
seclusion or restraint
Subcategory (check one)
1. Death during seclusion or restraint
2. Death within twenty-four hours of seclusion or restraint
3. Death related to or result of seclusion or restraint

Continued On Page 7 for Six Month Reportable Incidents

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 6 of 7

Six Month Reportable Incidents
The following lists and defines the incident data which must be reported every six months in accordance with
paragraph (G) of rule 5122-14-14 of the Administrative Code.
Category

Six Month Reportable Incident Definition

Injury Requiring
Emergency/Unplanned
Medical Intervention or
Hospitalization

An injury to a patient requiring emergency/unplanned medical intervention or
transfer to a hospital medical unit and which happens on the grounds of the
hospital or during the provision of care or treatment, including during hospital
off-grounds events.

Illness/Medical
Emergency

A sudden, serious and/or abnormal medical condition of the body experienced by
a patient that requires immediate and/or unplanned transfer to a hospital medical
unit for treatment, and which happens on the grounds of the hospital or during the
provision of care or treatment, including during hospital off-grounds events. A
medical illness/emergency does not include injury.

Seclusion

A staff intervention that involves the involuntary confinement of a patient alone
in a room where the patient is physically prevented from leaving.
The aggregate total number of all episodes of seclusion and aggregate total
minutes of all seclusion episodes.
The aggregate total number of all episodes of seclusion and aggregate total
minutes of all seclusion episodes.

Age 17 and Under
Age 18 and Over

Mechanical Restraint

Age 17 and Under
Age 18 and Over

Physical Restraint
excluding Transitional
Hold
Age 17 and Under
Age 18 and Over

Transitional Hold

Age 17 and Under
Age 18 and Over

A staff intervention that involves any method of restricting a patient’s freedom of
movement, physical activity, or normal use of his or her body, using an appliance
or device manufactured for this purpose.
The aggregate total number of all episodes of seclusion and aggregate total
minutes of all seclusion episodes.
The aggregate total number of all episodes of mechanical restraint and aggregate
total minutes of all mechanical restraint episodes.
A staff intervention that involves any method of physically (also known as
manually) restricting a patient’s freedom of movement, physical activity, or
normal use of his or her body without the use of mechanical restraint devices
The aggregate total number of all episodes of physical restraint and aggregate
total minutes of all physical restraint episodes, excluding transitional hold.
The aggregate total number of all episodes of physical restraint and aggregate
total minutes of all physical restraint episodes, excluding transitional hold.
A staff intervention that involves a brief physical (also known as manual)
restraint of a patient face-down for the purpose of quickly and effectively gaining
physical control of that patient, or prior to transport to enable the patient to be
transported safely.
The aggregate total number of all episodes of transitional hold and aggregate total
minutes of all transitional hold episodes.
The aggregate total number of all episodes of transitional hold and aggregate total
minutes of all transitional hold episodes.

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix A
Page 7 of 7

ACTION: Final

ENACTED
Appendix
5122-14-14

5122-14-14
DATE:
09/08/2011 12:39 PM
Appendix B

Inpatient Psychiatric Service Provider
Six Month Reportable Incident Data Report Form
Instructions:
Please complete the Inpatient Psychiatric Service Provider Information on this page. Please complete Parts A and B, beginning on Page 3. If the
hospital did not utilize seclusion and restraint during the reporting period, please complete Part C on Page 3. If the hospital did utilize seclusion
and restraint please skip Part C and complete Part D on Page 4. Definitions are found on Page 2.
You may submit this form by fax, e-mail or mail. Address and fax number information is available on the Ohio Department of Mental Health
website.
Please submit this report by the following deadline:
• For the incident reporting period of January 1 through June 30, by July 31 of the same year
• For the incident reporting period of July 1 through December 31, by January 31 of the following year
Inpatient Psychiatric Service Provider Information
Hospital Name: ________________________________________________________________ ODMH License Number: ________________
Person Completing Report: ___________________________________ Title: _____________________________________________________
Phone _____________________ E-mail: ___________________________

Reporting Period (please include year): 
 January 1 – June 30, 2_____ Report is due by July 31 of this year

 July 1 – December 31, 20_____ Report is due by January 31 of the following year

APPENDIX p(70517) pa(145502) d(331919) ra(285711)

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix B
print date: 09/08/2011 9:05 PM
Page 1 of 4

Definitions. Please utilize the following definitions for completing this report:
"Emergency/Unplanned Medical Intervention" means treatment required to be performed by a licensed medical doctor, osteopath, podiatrist,
dentist, physician's assistant, or certified nurse practitioner, but the treatment required is not serious enough to warrant or require transfer to a
hospital medical unit. It includes sutures, staples, immobilization devices and other treatments not listed under "First Aid", regardless of whether
the treatment is provided in the hospital, or at a doctor's office/clinic/hospital ER, etc. This does not include routine medical care or
shots/immunizations, as well as diagnostic tests, such as laboratory work, x-rays, scans, etc., if no medical treatment is provided.
"First Aid" means treatment for an injury such as cleaning of an abrasion/wound with or without the application of a Band-aid, application of a
butterfly bandages/Steri-Strips™, application of an ice/heat pack for a bruise, application of a finger guard, non-rigid support such as a soft wrap
or elastic bandage, drilling a nail or draining a blister, removal of a splinter, removal of a foreign body from the eye using only irrigation or swab,
massage, drinking fluids for relief of heat stress, eye patch, and use of over-the-counter medications such as antibiotic creams, aspirin and
acetaminophen. These treatments are considered first aid, even if applied by a physician. These treatments are not considered first aid if provided
at the request of the patient and/or to provide comfort without a corresponding injury.
“Hospitalization” means inpatient treatment provided at a medical acute care hospital, regardless of the length of stay. Hospitalization does not
include treatment when the individual is treated in and triaged through the emergency room with a discharge disposition to return to the
community or psychiatric inpatient unit.
“Illness/Medical Emergency” means a sudden, serious and/or abnormal medical condition of the body experienced by a patient that requires
immediate and/or unplanned admission to a hospital medical unit for treatment, and which happens on the grounds of the hospital or during the
provision of care or treatment, including during hospital off-grounds events. A medical illness/emergency does not include injury.
"Injury" means an event requiring medical treatment that is not caused by a physical illness or medical emergency. It does not include scrapes,
cuts or bruises which do not require medical treatment.
“Mechanical Restraint” means a staff intervention that involves any method of restricting a patient’s freedom of movement, physical activity, or
normal use of his or her body, using an appliance or device manufactured for this purpose.
“Physical Restraint”, also known as “manual restraint”, means a staff intervention that involves any method of physically (also known as
manually) restricting a patient’s freedom of movement, physical activity, or normal use of his or her body without the use of mechanical restraint
devices.
“Seclusion” means a staff intervention that involves the involuntary confinement of a patient alone in a room where the patient is physically
prevented from leaving.
“Transitional Hold” means staff intervention that involves a brief physical (also known as manual) restraint of a patient face-down for the purpose
of quickly and effectively gaining physical control of that patient, or prior to transport to enable the patient to be transported safely.

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix B
Page 2 of 4

Part A. Service Utilization (Please continue to Part B when finished)
Definition:
“Patient Days” means the sum of all census days less the sum of all leave days (authorized or unauthorized absences when patient is not under
direct supervision of psychiatric care setting staff).
January/ February/
March/
July
August
September

April/
October

May/
June/
November December

Total Number of Patient Days per Month

Part B: Incidents, Excluding Seclusion and Restraint (Please continue to Part C when finished)

 Hospital has no Table B1 incidents during the reporting period. Please continue to Part C.
Table B1
Incident Category

January/ February/
March/
April/
May/
June/
July
August
September October November December

Injuries Requiring Emergency/Unplanned Medical Treatment or
Hospitalization
Number of injuries, excluding patient falls, requiring
emergency/unplanned medical treatment or hospitalization.
Illness / Medical Emergency
Number of illnesses/medical emergencies, requiring immediate
and/or unplanned admission to a hospital medical unit

Part C: Seclusion / Restraint Episodes

 Hospital did not utilize seclusion or restraint during the reporting period.
If Box in Part C is checked, you are finished. Please return report.
If not, please complete Part D

Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix B
Page 3 of 4

Part D: Seclusion / Restraint Episodes
January/
July

February/
August

March/
September

Seclusion for Ages ≤17 
 None
Number of episodes of seclusion for ages ≤17
Total minutes of all seclusion episodes for ages ≤17
Seclusion for Ages ≥18 
 None
Number of episodes of seclusion for ages ≥18
Total minutes of all seclusion episodes for ages ≥18
Mechanical Restraint for Ages ≤17 
 None
Number of episodes of mechanical restraint for ages ≤17
Total minutes of all mechanical restraint episodes s ≤17
Mechanical Restraint for Ages ≥18 
 None
Number of episodes of mechanical restraint for ages ≥18
Total minutes of all mechanical restraint episodes for ages ≥18
Physical Restraint for Ages ≤17 
 None
Number of episodes of physical restraint, excluding transitional hold,
for ages ≤17
Total minutes of all physical restraints episodes, excluding
transitional hold, for ages ≤17
Physical Restraint for Ages ≥18 
 None
Number of episodes of physical restraint, excluding transitional hold,
for ages ≥18
Total minutes of all physical restraints episodes, excluding
transitional hold, for ages ≥18
Transitional Hold for Ages ≤17 
 None
Number of episodes of transitional hold for ages ≤17
Total minutes of all transitional hold episodes for ages ≤17
Transitional Hold for Ages ≥18 
 None
Number of episodes of transitional holds for ages ≥18
Total minutes of all transitional hold episodes for ages ≥18
You are finished. Please return report. Thank you.
Ohio Department of Mental Health
OAC 5122-14-14 Inpatient Psychiatric Service Provider Appendix B
Page 4 of 4

April/
October

May/
November

June/
December



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Title                           : Lawriter - OAC - 5122-14-14 Incident notification and risk management.
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