Complaint Investigation Report

sufficient evidence to conclude that staff did not put forth effort to protect C2 and C3 from C1’s aggression. The evidence indicated that staff put forth measures and made attempts to redirect C1 and to reassure and shield C2 and C3 from aggression and intrusion.

It was also alleged that Client 4 (C4) often yelled repeatedly inside and outside of the home, and staff did not take measures to address or protect C4. It was reported that C4 would repeatedly scream or cry out “no,” “stop,” and “help” in a blood curdling manner, and it was unclear whether C4’s screams were in response to harm. A review of records obtained during the investigation indicates that C4 has diagnoses of autism spectrum and schizoaffective disorders and has limited communication. In addition, C4 moved into the home during the COVID-19 pandemic, which caused a disruption in C4’s schedule and prevented participation in school and/or programs that provided consistency and familiarity for C4. Records reviewed reflected that clear directions of ways in which to respond to C4’s outbursts had been developed and were included in care plans maintained in the home. Interviews conducted during the investigation yielded that outbursts from C4 were not uncommon; however, the outbursts were not in response to any harm being done to or inflicted upon C4. Interviews further revealed that staff followed the directions in C4’s service plans, which were developed in consultation with behavioral consultants, when responding to or addressing C4’s outbursts. The investigation did not yield evidence to conclude that C4 was subjected to harm while in care or that staff did not address C4’s outbursts.

The second allegation is that C2 was left in soiled clothing for an extended period of time. A review of records maintained by the facility, reflected that C2 has a documented history of urinary incontinence. Interviews revealed that C2 often urinated while in bed, and there were plans in place for staff to prompt C2 to get up and use the restroom. Interviews further revealed that C2 often stayed in bed late into the day, despite staff promptings. LPA was also informed that, at times, C2 would demonstrate physical and/or verbal aggression toward staff, if overly prompted. Information obtained during the investigation indicates that staff made attempts, through ongoing prompting, to get C2 out of bed to prevent episodes of urinary incontinence. It was determined from information gathered during the investigation that C2, who, according to his/her Individual Behavior Support Plan, is able to advocate for her/himself, would exercise her/his right in refusing to get out of bed before and after episodes of urinary incontinence. The investigation did not yield evidence to conclude that C2 was left in soiled clothing for extended periods of time because of lack of action on the part of facility staff, but that C2 exercised their personal right and chose to remain wet, in spite of attempts and efforts to convince C2 to do otherwise.