Complaint Investigation Report

Regarding the allegation that, “Staff do not follow resident care plans” it was reported Staff 2 (S2) provides extra food for Client 2 (C2) resulting in aggressive behavior episodes. LPA reviewed the facility’s program design. Per the facility’s activity schedule, clients are provided one daily snack. S2 reported they have provided C2 with extra food to calm them down during a behavior episode. Per the program design, some of the behavior support techniques used by the facility are positive reinforcement of appropriate behaviors, response cost contingencies in which stimuli and rewards are removed and remain contingent upon behaviors and reinforcing coping skills by venting anger or frustration in a more appropriate way. The program design states the facility uses modeling prompts, praise, and verbal reinforcement to manage aggressive behaviors. Therefore, if C1 expressed a behavior episode or frustration, providing them with extra snacks to calm them down would contradict the facility’s behavior support techniques and interventions noted above. As a result, the allegation is Substantiated.

Regarding the allegation, “Staff did not ensure clients were supervised appropriately” it was reported S2 left Client 3 (C3) unsupervised resulting in C3 getting out of their wheelchair and removing their clothes. S2 reported leaving C3 with Staff 3 (S3) for a moment as S2 assisted another client to the restroom. LPA was unable to corroborate S3 was asked to supervise C3. S2 stated they returned to find C3 down the hall, alone and without a top and undergarment. LPA reviewed C3’s Individual Program Plan, which notes that C3 requires constant supervision during waking hours to prevent injury/harm in all settings/situations as they do not possess or exercise appropriate safety awareness. LPA reviewed the facility’s program design, which states the staffing schedule is based on a 1:3 staff-to-client ratio. As a result, the allegation is Substantiated.

Regarding the allegation, “Clients not accorded dignity in relationships with staff” it was alleged that Client 4 (C4) had blood dripping down their leg and S1 disclosed details of C4’s personal health information with other facility staff in the presence of clients rather than providing immediate assistance. Information obtained from interviews and S1 corroborated the allegation and added that S1 used hand gestures to point at C4’s genital area. Based on interviews conducted, the allegation is Substantiated.