Complaint Investigation Report

Based on a review of R1’s behavioral progress notes, dated October 22, 2021, R2 was sitting in the couch in the living room and R1 was also sitting on the other side of the living room. Staff went to R2’s room to get a jacket, the staff heard R2 screaming. Staff then went to investigate and saw R2 with blood on his/her face.

Based on a review of a facility Special Incident Report dated October 22, 2021, states, R1 hit R2. R1 was claiming R2 spit on him/her. Staff stated they did not observe R2 spit on R1. The report also states the following “R1 is very sneaky and times it just right that when he/she sees the staff getting busy or assisting another staff who is helping another resident, that is the time when R1 hit R2 in the head, splitting his/her eyebrow.”

On February 21, 2024, LPA Monter interviewed 4 residents (R3-R6.) R2 stated he/she did not witness when R1 hit R2 on October 22, 2021. R2 stated the staff does intervene when R1 tried to hurt them. R3 stated that R1 once knocked out a staff while they were trying to protect them. Residents R4 and R5 did not responded to LPA’s questions due to developmental disability. Resident R6 stated he/she did not want to be interviewed.

On May 14, 2024, LPA Monter interviewed staff S1-S4. All staff interviewed stated they were trained regarding R1’s behaviors. 4 Out of 4 staff interviewed stated R1 would try to hit the residents and staff. S3 and S4 stated R1 was difficult to prompt because he/she would ignore staff and try to hit residents because he/she wants to move back home. 4 Out of 4 Staff interviewed (S1-S4) stated they don’t remember what had occurred on October 22, 2021. S1 and S3 stated they remember staff contacting 911, because R2 was struck. S2 stated S2 stated he/she thinks he/she wasn’t working that day, but is having trouble remembering. S4 stated he/she doesn’t remember clearly what had occurred, but does remember staff was present, and separated R1 and R2, then 911 was called.

Based on a review R1’s Individual Program Plan (IPP), dated December 4, 2019, and R1’s Appraisal/Needs and Services Plan (ANS), dated August 7, 2021, R1 is reported to be verbally aggressive at home and at school, and has become physically aggressive with his/her family. R1 is reported to display maladaptive behaviors such as verbal aggression, physical aggression, lying, stealing and property destruction. Both the IPP and ANS state R1 does not have 1:1 staffing.