Complaint Investigation Report

The staff will just stand outside the door to observe and be on stand by if clients need anything. S2 also shared that if clients show behaviors they try to hold their hands and talk to them. By holding the clients hands carefully, they talk to clients slowly and tell them to calm down and to also prevent clients for hurting themselves. With regards to blocking the doorway, staff are there for the clients safety, for them not to run out on the street. For the client (R2), he/she is always half dressed coming from the home. That is part of the behavior.

Regarding the allegation of Staff are not properly trained, RP stated that the two assigned staff did not intervene, nor did the program’s crisis intervention trainer—who is also the administrator. This raises concerns about staff training, proactive intervention strategies, and overall supervision in the program. RP have observed what appears to be staff restraining R1 by his/her hands and escorting R1 by force. If staff are unable to anticipate and intervene appropriately in behavioral incidents, both participants and staff remain at risk. During one visit, a participant requiring two-to-one staffing struck RP in the head.

LPA interviewed S1, who is one of the staff assigned to R1. S1 shared that they are aware and knows what behaviors R1 has. In order to help de-escalate R1 when he/she is showing behaviors, S1 puts their arms under the armpits and assist the client to walk. S1 also mentioned that the person struck was not hit by an object but water coming from the beanie that R1 wore and was soaked. S1 mentioned that R1 has that behavior of flinging objects. PD also shared that RP was advised beforehand of the behavior of R1. S3 also shared that the behavior happened because RP had staff return R1 to the program when staff was trying to de-escalate the behavior by walking R1 around the area. R1 got more agitated when the staff returned back to the facility.

Based on records reviews, the resident (R1) has different behaviors such as spitting, vomiting, flinging/smearing of biohazardous materials.