Complaint Investigation Report

It was alleged that staff (S1) is not competent in handling residents who are going through a crisis. It was stated that instead of de-escalating a crisis, S1 escalates the resident’s crisis by asserting control by holding his/her ground when R1 is actively going through an episode, avoiding eye contact, and speaking to R1 at a loud volume. This was observed by witnesses during an incident on 10/15/2024.

On 10/15/2024, an incident occurred wherein R1 was being verbally aggressive towards the staff after medication and items that could be of danger to the resident and others were found and confiscated inside R1’s room.

Based on interview with staff (S1), on 10/15/2024, during rounds, S1 observed medications and multiple items which could be of danger to the resident and others inside R1’s room. When S1 informed R1 that the items were going to be confiscated, R1 became upset.

S1 stated that R1 was yelling in S1’s face within a few feet apart. When R1 was yelling in S1’s face, S1 stated that he/she did not step back and stood his/her ground. S1 states he/she did not step back because he/she knew that R1 would not be physical with S1. S1 stated that during the incident S1’s tone of voice raised “a little”, but S1 denied yelling or being angry at R1. S1 stated that he/she initially approaches the residents in a low tone of voice but if the resident is not listening, S1’s tone of voice increases to be more persuasive.

S1 states that during a resident’s crisis, S1 has observed that the treatment team and crisis team walks away from the situation. S1 states that he/she does not walk away but instead confronts the situation because of the need to “take care of it”. S1 states he/she does not step back because he/she knows that the residents will not be physical with the staff and are only verbally aggressive.