Complaint Investigation Report

facility. RP states S1, S2, and S3 make inappropriate comments that lack dignity and/or respect to clients. Such comments include derogatory references of clients’ appearance and behavior. RP states S2 stated to Client 2 (C2) that C2’s pimples were gross and started “popping” C2’s pimples. RP states Amy West, Program Administrator (PA) issued a facility staff memorandum (“memo”) to all staff regarding the proper manner in which to treat the clients in care. RP states S1, S2, and S3 did not follow the memo and claimed it to be “stupid” and “useless”. Records reviewed and interviews conducted revealed on 1/31/2021 during a 7 am – 3 pm shift, S1, S2, and S3 were in the staff office for long periods of time, leaving only one staff member supervising and attending to 4 of the 5 clients’ needs for large periods of time. Records reviewed revealed on 2/3/2021, S3 was assigned to providing care and supervision to C2 however at that time, S1, S2, and S3 were in the facility staff office for at least 30 minutes during breakfast time leaving C2 to be provided breakfast by another staff member who was not assigned to C2, and not in accordance with required staffing ratios. Records reviewed revealed when S3 exited the staff office, S3 “got mad” that C2 had been given breakfast because S3 had planned on taking C2 out to get coffee. Records reviewed and interviews conducted revealed on 2/8/2021, S1, who was assigned to Client 3 (C3), was spending time on S1’s personal phone ‘Facetiming’ with family. S1 left the facility at approximately 9:00 or 9:30 pm stating C3 was asleep. Records reviewed and interviews conducted revealed C3 was not asleep and C3 was active throughout the facility. On 2/11/2021, C2 was “exhibiting precursor and challenging behaviors “(anxious, pacing, slamming doors, taking clothes off, hitting self)”. S1 was observed to repeatedly tell C2 to “sit down”, “get out” “kitchen closed”, “stop yelling” “you don’t even know what you want”, “just go to bed already”, then S1 locked the bathroom door to prevent C2 from using the bathroom. Records reviewed and interviews conducted revealed on 2/10/2021, S1 was heard to say C1 needed to be restrained and did not need to report the restraint because it was only one time and only lasted a few minutes. On 2/12/2021, staff observed C2 to have a ‘Self-Injurious Behavior’ (SIB) injury. Records reviewed revealed on 2/12/2021, PA went to the facility to inquire about an injury C1 had from what appeared to be a SIB. During the inquiry, it was reported to PA that the previous day staff had been derogatory and disrespectful to the clients, and the individual making this statement believed the staff’s behavior was a contributing factor to C1’s behavior and that there were more challenging behaviors when certain staff were working. Records reviewed and interviews conducted revealed on 2/14/2021, S2 was observed to grab C2 and pulled C2 down to sit in a chair; when C2 did not sit down, it was observed that S2 stated “you don’t need to eat more”, “you’re fat”, then S2 grabbed C2’s stomach and wiggled it in S2’s hand.