Facility Evaluation Report

On 12-31-24 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding multiple reported incidents. LPA met with Program Administrator (PA) Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with PA and reviewed incident reports dated between 12-11-24 to 12-30-24. LPA also reviewed staff training documentation and current service plans for resident1 (R1) and R2.

Incident #1: On 12-10-24 at approximately 3:00pm, resident2 (R2) engaged in grabbing staff in the chest area. Staff on duty attempted to redirect R2 to an area away from others for de-escalation purposes. During this attempt, Staff2 (S2) began walking towards PA and was redirected again by staff using a turnaway technique to prevent potential injury and escalated behaviors.

Incident #2: On 12-28-24 at approximately 7:40am: Resident1 (R1) engaged in combativeness with a staff member. Staff5 (S5) stepped in to use crisis preventative institute (CPI) disengagement strategies while additional staff used verbal redirection. R1 continued to engage in various property destruction, and S3 utilized a CPI low level turn away procedures at various points of the interaction for safety purposes. R1 returned to baseline behavior within 30 minutes of the de-escalation techniques. Medications were given to R1 per physician's orders to aid in de-escalation.

Incident #3: On 12-29-24 at approximately 5:45pm, R1 became fixated on a staff member and was verbally redirected by another staff member on duty. At approximately 9:00pm, R1 became combative with staff. Medications were given by staff per physician's orders. At approximately 9:55pm, R1 began chasing staff with a mop and was verbally redirected by staff. Shortly thereafter, according to incident report, R1 continued to hit and spit at staff, and at approximately 10:15pm, S1 and S2 placed R1 in a medium level standing hold for approximately 30 seconds. R1 then returned to baseline behavior shortly after the hold according to incident report. {Cont. on 809C}