Complaint Investigation Report

Facility staff and clients were at the gym 10 minutes when C1 went to the restroom at the gym. When C1 came out staff encouraged them to minimize use of the restroom at the gym because they were spending about 15 to 20 minutes in there unsupervised. Staff were unable to supervise C1 while in the restroom due to the gym being open to the public and utilizing segregated men’s and women’s restrooms. As all staff supervising the clients at the gym were female, they could not enter the male segregated gym bathroom to supervise male clients. Upon exiting the restroom and being spoken to by facility staff, C1 began to experience behavioral issues including physical and verbal aggression. C1 began hitting and biting themselves and said they were leaving the gym to walk home. According to the UIR, S1 told C1 to wait for the rest of the clients which caused C1 to start swinging punches attacking S1. This behavior by C1 continued all the way back to the facility where C1’s relatives were waiting. According to the UIR, C1 went on to attack their relatives physically and verbally. Staff interviewed by LPA stated that sometimes when C1 gets very upset they self-harm including pulling on their own ears very hard and biting themselves very hard. C1 will also begin to shake uncontrollably. Staff stated that S1 is usually able to calm C1 down, but during this incident they observed C1 displaying physical signs of behavioral issues. Staff stated to LPA that during the incident involving C1, they saw S1 at the gym attempting to block themselves from the punches being thrown by C1 but did not see S1 use any type of physical aggression. The facility Preplacement Appraisal Information for C1 states that C1 has a history of mental/emotional behaviors resulting in harm to self and others including verbal and physical aggression. Documented behavioral services agency evaluations for C1 stated that C1 has exhibited several instances of verbal outbursts/yelling and needs space and/or isolation. Evaluations for C1 also state that traditional reinforcements for good behaviors can cause C1 frustration and escalation. Outside agency Individual Program Plans (IPP) and psychological evaluations/behavior support plans for C1 indicate that C1 has frequent behavioral issues including verbal outbursts/yelling, as well as physical aggression/self-injurious behavior including pushing, biting, hitting, kicking others, and biting and/or hitting themselves. Based on the information gathered, there is insufficient evidence to prove S1 physically abused C1. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff caused injury to resident in care. It is alleged that C1 had scratches on their neck and arms as well as ripped skin behind their ear due to the alleged incident of physical abuse by S1.

Through interviews with facility staff and record review of C1’s relevant documentation, LPA learned that when C1 gets very upset they can experience episodes of physical self-harm including pulling on their own ears very hard and biting themselves very hard. Continued on 9099-C