Complaint Investigation Report

R1’s IPP states that R1 prior to having a medication change, R1 used to have a maladaptive behavior of banging R1’s head. R1’s Ongoing Progress Notes state that on 03/29/2023 at 6:30 AM “[R1] bump his head in the kitchen wall without reason. Affected area applied with ice pack and triple antibiotic.” The entry at 5:30 PM the same day states “When we called [R1’s] mom on Facetime, [R1’s] mom asking what happened [R1] said ‘I bump my head in the kitchen.” Mom said why? [R1] said [S2] hurt my feeling because I lied to [S2], [S2] got mad. I miss Flamingo.”

The second page of R1’s Emergency Contact Information form, which states it was prepared by ADM, states that “[R1] also loves to eat and does not know when to stop not until redirected.” R1’s Hospital Visit Progress Notes dated 05/06/2020 state that “obesity” is listed as an item under the “Problems List” section. R1’s IPP report from 04/05/2021 states “[R1] has no control over eating food. [R1] eats fast and excessively. [R1] is supervised closely during meals for risk of choking.”

During interviews, R1 stated that S2 yelled at R1 and took R1’s meal away. R1 stated to have hit R1’s head on the kitchen wall.

During interviews, S1 and S2 stated to have never taken R1’s meal away or to have ever yelled at R1. S1 and S2 stated to have never observed any other staff take R1’s meal away or yell at R1. Both S1 and S2 stated to have never caused any injury to R1, including to R1’s head or face, and to have never observed another staff do so either. S2 stated that S1 applied first aid to R1’s head injury when the incident occurred.

During interview, ADM stated to have never hit or caused injury to R1 and to have never observed a staff do so either. ADM stated to have never observed a staff take a meal away from R1. ADM stated that there was one incident in which R1 returned from Day Program with another client’s food in a container. ADM advised R1 to give back the food and the container since they belonged to someone else.

ADM stated that R1 sometimes hits R1’s head on walls and other objects when R1 becomes frustrated or upset. ADM stated that ADM recently took a vacation and R1 was very upset at that time due to missing ADM. ADM stated that the incident in which R1 hit R1’s head against the kitchen wall on 03/29/2023 occurred while ADM was on vacation.