Complaint Investigation Report

According to outside sources, the facility staff attempted to de-escalate the situation by communicating with C1’s family to no avail. After the facility staff’s communication with the family, they were required to contact law enforcement for further assistance. Two responding Officers arrived at the scene. According to outside sources, C1 was agitated and said that they wanted to hurt themselves. Facility Administrator spoke with the officers, but who were reluctant to assist with C1, and did not want to call in an involuntary psychiatric hold. Law enforcement directed the Facility Administrator to pick-up C1 from the DP or have the client medically transported. Facility staff attempted to arrange transport but was unable to due to lack of insurance coverage. The facility administrator drove to the DP but did not want to transport C1 due to safety concerns about C1’s aggressive behavior. According to Facility Administrator, they attempted to contact various medical transport services to assist, but none would cover those services. According to outside sources, law enforcement was contacted four times for assistance, but officers were reluctant to assist. According to the Administrator, they requested for a Psychiatric Emergency Response Team (PERT) but instead the same responding officers arrived, and said they were PERT certified. At approximately 3:00 PM law enforcement contacted an ambulance. Interview with outside service agency corroborated all the administrator’s statements.

A review of records revealed that the incident transpired on 2/08/23, C1 was having a behavior and 911 was initiated. Upon law enforcement arrival, C1 attempted to hit a police officer and stated their intent of self-injurious behavior. C1 continued the behavior until approximately 3:00 pm when an ambulance arrived. Additional records revealed that 911 transcript showed a recurring call at 1:47 pm with multiple units responding for C1 hitting staff and other clients. It described that C1 was threatening to hurt themself and others. According to reports, C1 had been on a psychiatric hold two weeks prior and was having random outbursts but did not pose a threat and was not able to cause physical harm. According to records, the facility administrator requested assistance with transport which was refused. C1 hit the administrator several times and so staff contacted 911 again and requested for a PERT team but the same responding officers arrived. The final time the officers responded, it was determined that the client needed to be treated and an ambulance was contacted. According to C1’s Placement Referral information, C1 had behaviors of aggression towards self, others, and property. There were documented episodes of physical aggression, property destruction, suicidal and homicidal ideations (SI/HI), and threats to others.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated.