Complaint Investigation Report

• Client Information Sheet • Admission Agreement • Agreements and Consent for Medical Treatment

• Personal Rights • Individual Program Plan (IPP) • Behavior Consultant Notes • Special Incident Reports

• Hospital/Medical Reports • Facility Client Notes • Body Assessment Sheet • Staff Roster • Client Roster • On-The-Job Training job for S1 and S1 • CPI Certificates for S1 and S2

The investigation revealed the following;

Allegations: Resident was not allowed to have a snack and Staff restrained resident. The details of these allegations state that on 11/5/21, at 5am, C1 asked for a snack from S2 because he felt hungry and S2 denied him snacks which caused C1 to get upset and attack S2. AS a result, staff placed him on a CPI hold.

Based on interviews conducted, the statements obtained were consistent and corroborated with these allegations. During the interview of C1, C1 stated that on the morning of 11/5/21, he asked S2 to warm up his left-over food from the night before but S2 refused and told him to go back to his room which made him upset and as a result he attacked S2. S1 and S2 than placed C1 on a CPI hold. Interviews conducted of the Administrator and S1 confirmed that the incident was a result of S2 refusing to serve a meal to C1, on the morning of 11/5/21, at 5am. After the incident, the Assistant Administrator conducted an in-service training with staff on the importance of having the kitchen open for clients, regardless of time of day. During the visit conducted on 11/22/21, the Assistant Administrator was unable to provide documentation if a debriefing session was held within 24 hours after C1 was placed on a CPI hold on 11/5/21. The purpose of the debriefing session is to help assess whether the intervention was necessary and was implemented in a manner consistent with staff training and facility policies. As required by Section 1180.5(d), debriefings must be documented by facility staff in the client’s record and must document any changes to the needs and services or treatment plan as a result. The SGPRC also conducted an investigation and the following recommendations were made;

• Ensure to Complete an in-service regarding Client Rights Training – interviews indicate the incident began after C1 was told that he could not microwave his food at 5am because it was “too early” in the morning and other residents were still sleeping.

• Ensure CPI training for S1 and S2. Interviews indicate that S2 placed his arm diagonally across C1’s chest/waist area as they both sat on his bed. S2 explained that placing his arm across C1’s chest/waist area (like a seat belt) was to ensure that he did not “go after” S1 as she was collecting C1’s belongings. An Arm placed across an individual’s chest area is not a certified CPI technique. Also, it does not appear that