Complaint Investigation Report

On 01/03/2022, a Crisis Counselor noted that staff reported to sometimes place R1 in a restraint when R1 is aggressive because they worry R1 will harm others. During question, staff stated to use restraint on R1 last week and the restraint can go up to two hours at a time or until R1 calms down.

Based on interview, on 12/29/2021, the Administrator stated to be a trainer of Pro-Act and has taught some techniques to staff but has never held a formal training nor documented the staff training on Pro-Act.

Based on record review, on 06/12/2021, seven out of nine staff received training on understanding challenging behaviors. Seven out of nine staff received training on supporting individuals in a person-centered way. On 08/18/2021, seven out of nine staff received training on medication management and compliance. On 09/20/2021, nine out of nine staff were provided in-service training on items included but not limited to behavioral support plans and when to implement proactive vs reactive strategies.

The review of facility staff training records did not indicate staff were provided training nor obtained a certificate of completion of Emergency Intervention training.

Staff is keeping resident locked in the room

On 01/03/2022, R1 was observed locked in the bedroom without supervision by an outside agency. R1 was not observed to be in crisis at that moment the bedroom door was locked.

Two out of two witnesses were interviewed. Two out of two witnesses confirmed to observe the staff locked R1 in the room during their facility visit.

Three out three staff were interviewed. Three out of three staff confirmed that R1 was locked in bedroom of the facility

Based on record review, on 01/03/2022, visit notes were provided from an outside agency to R1’s responsible party regarding the observation of staff locking the client’s bedroom while the client was inside. In another instance that day, it was noted that staff locked the door again after the client went back into the room from the restroom. Staff stated R1 would be locked in the room for five to ten minutes but knows it’s unsafe, so they do not do it often.