Complaint Investigation Report

On 3/9/22, at approximately 12:30 AM, R1 was reported, in an incident report, to have awoken and been incontinent. The report further stated that as S1 and S2 attempted to have R1 change their clothes, R1 declined to change and was focused on something else that they wanted. When R1’s request was denied until they were changed from their wet clothes, R1’s behavior escalated to property damage and self-injury.

Staff initiated emergency intervention techniques that resulted in R1 having a prone, 2-person restraint for approximately 5 minutes. Following the intervention, R1 was seen my emergency responders for self-injuries.

R1’s Functional Behavior Assessment / Individual Behavioral Support Plan last updated 5/2021 states that “Merakey utilizes only ProACT containment as a last resort. Merakey only approves a standing containment or a wall containment as a last resort”. S1 and S2 stated that R1 lowered himself to a prone position on 3/9/22 and that they then held him there in order to limit further self-injury.

It is then alleged that S1 made statements on 3/23/22 to other staff members that on 3/9/22 in an intervention with R1, that S1 made statements of getting “kicks in”, putting their full weight on R1 and taunting R1 with “this is what you wanted”.

LPA Mknelly interviewed staff who were present on 3/9/22 at the time of R1’s incident and staff who were present on 3/23/22 for the alleged statements.

No other staff person made statements when interviewed of witnessing S1 abuse R1 on 3/9/22. Furthermore, no other staff person made statements when interviewed of witnessing S1 making the alleged statements on 3/23/22.

S1 and S2 acknowledged that the prone containment used on 3/9/22 was not approved in Merakey policy nor R1’s intervention plan for the prone containment.