Complaint Investigation Report

Interviews and review of incident report revealed R1 began to throw items while asking to see his family member. Facility staff heard banging in the room and were unable to determine if R1 was banging his head or other body part. Facility staff then attempted to look through R1’s window from the outside, however, R1 had closed blinds. Facility staff attempted verbal de-escalation techniques but were unsuccessful. Interviews and incident report further revealed that staff were instructed to call R1’s responsible party for additional de-escalation techniques, but did not call 9-1-1 for intervention after learning of R1 barricading self in room along with concerns for physical safety. R1 opened door after speaking with responsible party at approximately 6:50pm. Facility staff assessed R1 for injuries and determined that R1’s forehead and back of head were red. R1 was transported to hospital by staff. No major injuries were noted as a result of this episode.

A review of R1’s IPP and needs and service plan revealed R1 has a history of self injurious behavior including head banging. Interviews conducted revealed facility staff stating that in hindsight, calling 9-1-1 would have been a better option.

As a result of this investigation, the preponderance of evidence standard is met, therefore, this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. A civil penalty in the amount of $250 is issued in addition to the citation due to repeat violation of Section 80078(a) within a 12 month period. An exit interview was conducted with licensee designee and a copy of this report was provided via email with request to return with signature. Appeal rights and LIC 811 provided.