Complaint Investigation Report

Allegation: Facility staff locked a client in their bedroom. It is alleged that NOC shift Direct Support Professional (DSP)/staff (S1) locked client (C1's) bedroom door during the night shift. It is unknown if the door was locked all night or only during early morning. According to information obtained, at approximately 7:06 AM, day shift DSP/staff (S2) went to check on C1 and noticed the door was locked. Client (C1's) bedroom doorknob is a privacy door knob that has a twist lock that works from only one side, commonly used for privacy in bedrooms. The door knob is a non-key knob that may be unlocked with a coin,fingernail, or any other key. Staff (S2) stated they unlocked the door using their fingernail. Based on record review, C1 has profound intellectual disability and does not have the mental capacity to unlock a door. Client (C1) is non-verbal and was not interviewed. In order to observe the C1's mental capacity, LPA asked Administrator to direct C1 into C3's bedroom, which currently has the same doorknob C1's room had at the time of the incident. The lock was placed on the door and C1 was instructed to open the door. The client was unable to unlock or open the door, then the interior doorknob lock was unlocked, and the C1 was asked to open the door. When the interior doorknob was unlocked C1 was able to exit the room by pushing the unlocked doorknob. Staff (S1) denied the allegation and stated they closed C1's door because they had understanding that the client was able to come in and out of their room, and did not know C1 lacks mental capacity to unlock the doorknob. Staff (S1) stated they were a new employee and the date of the incident was the first NOC shift they worked alone. A total of five (5) staff were interviewed. Staff stated that whenever C1 is wet with urine the client opens the bedroom door and comes out and communicates non-verbally with staff, informing staff that they are soiled and/or wet. On March 26, 2025, when S2 unlocked C1's bedroom door they found the client heavily soiled. The findings indicate S1 locked the client's door, and C1 was unable to exit their bedroom.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Assistant Administrator Ann Hyde. A copy of the report and appeal rights were provided.