Complaint Investigation Report

Reporting party states C1 is supposed to have 2 staff present 24/7 and “the incidents occurred due to severe neglect”. LPA reviewed the facility schedule and interviewed 10 staff. Intervi e ws revealed staff are always in ratio since April 2023, and 2 staff were always working with C1 and staff did not work alone. Staff schedules show an open shift in the afternoon on 4/5/23, 4/6/23, 4/11/23 and an open shift in the morning on 4/9/23 and 4/17/23. Staff interviewed stated when there is an open shift or a staff calls out the Staff in Charge (SIC) steps in until a substitute can fill in. Staff also state sometimes the Administrator works a shift and all staff take the ratio seriously to protect C1. All Staff interviewed stated they believe they are properly trained in de-escalation, redirection and restraints to help prevent C1 from harming themselves. Staff implement redirection as soon as possible and restraints a s appropriate in the safest way possible to prevent C1 from self-harming. Incident reports and restraint logs show C1 was restrained on 4/16/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/21/23, 4/22/23, 4/22/23, 4/23/23 and 5/20/23 to help prevent C1 from self-harming. One staff stated that on Sunday, 4/23/23, C1 was having a hard day and kept hitting/punching their eye. The staff indicated they followed C1’s behavior plan and tried breathing and counting exercises with C1, but ultimately implemented a one-person restraint for less than 30 seconds to try to deescalate C1 and try to prevent SIB (Self-Injurious Behavior) to the eye. C1 is in the highest level facility licensed by Community Care Licensing. The investigation revealed C1 has a care team of over 10 professionals that meet monthly to ensure C1 is on track and R1’s goals and needs are being met. The care team includes a Board Certified Behavior Analyst (BCBA), a Quality Behavior Modification Professional (QBMP), Assistant Supervisor, Program Administrator, and a Program Coordinator. C1’s nurse is present at the facility every week for 10 hours, and is also contacted if any medical issues arise. The nurse communicates with R1’s PCP doctor who sees R1 in-person once a month. Administrator interview revealed that staff training is very comprehensive, and staff constantly monitor R1 to ensure R1’s care plan is being followed. This care plan helps ensure C1 is meeting monthly goals and all of C1’s needs are being met. Based on the information obtained the allegations Staff failed to meet resident’s needs and staff were not in ratio are deemed Unsubstantiated.

On the allegation: Staff violated resident’s visitation rights. It was alleged that staff isolated C1 from their family while in the hospital and only allowed the family to visit once a day for an hour, violating their personal rights. Client 1 (C1) has a conservatorship where the conservator has full rights over C1 including placement and visitation. The conservator outlined Visitation Guidelines for C1 and has the authority to change and alter it. On 1/27/23 the Limit of Powers of Temporary Conservatorship was petitioned and court and a judge denied the request on 08/11/2023. Continued on 9099-C