Complaint Investigation Report

Based on records review, there have been several incidents reported that has happened in the facility regarding R1s behavior. R1 has been verbally aggressive to facility staff and residents. R1 has also physically hit some residents. R1s crisis plan notes that to only communicate when R1 is calm. If there is imminent risk of serious injury, contact 911. Part of the facility’s Program Plan is that it will work as a team with social workers, parents, schools/day programs, and consultants identifying and developing plans to address resident behavioral issues. All behaviors and interventions will be documented on the data collection forms or in the ongoing notes. Staff will be instructed in the prudent use of Crisis Team and 911 personnel to contain unsafe behavior episodes.

Regarding the allegation of facility did not pick up resident after discharge, RP stated that the staff called facility to inform them that the client was ready for discharge. However, the administrator refused to pick up the client.

LPA interviewed administrator and it was mentioned that, around dinner time of the same day, R1 was being released. Administrator to them to put a hold first since he needed to talk to the residents to assess how they are doing. Residents at the facility were still scared and upset. Behavior consultant also advised to assess residents and R1 first before pushing fort with the release from Emergency Psychiatric Service (EPS). Administrator also called EPS after assessment and consultations to keep R1 for the night and see the following morning if he was stable. The following day another reassessment was done and residents in the facility had been debriefed, and then R1 was picked up from EPS.

Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.