Complaint Investigation Report

Resident sustained multiple injuries due to lack of supervision/neglect:

R1 was assigned a 1:1 direct care staff for 8 hours a day according to R1’s Individual Program Plan (IPP). R1 was never left unsupervised in the facility unless R1 asked for privacy or space. Facility staff provide a safe environment and respect the wishes of their clients. The facility staff do not bother or check the clients unless absolutely necessary or when requested by the client themselves. On 9/15/2022, R1 asked for privacy and went into R1's room. Around 5 minutes later, R1 exited R1's room and asked staff for help. R1 inserted a colored pencil into R1's private area. The facility called 911 and sent R1 to hospital immediately. Staff were aware of R1’s history of inserting objects into R1’s private area and had made arrangement for items to be stored and locked away. After the incident, the facility brainstormed ideas on how to keep R1 safe. The facility agreed to store crayons, color pencils and other writing instruments out of R1’s reach and monitor it closely. ADM pushed for additional 1:1 funding for R1, and increased staffing at the facility to account for R1’s behaviors and other residents in care.

Resident was not accorded a safe accommodation to meet his needs:

On 10/10/2022, the Department interviewed 5 staff members and ADM. R1 has maladaptive behaviors that continues to escalate while at the facility because R1 has learned to push boundaries while staff re-direct R1 and provide other options. R1 refused to listen to staff directives and did what R1 wanted. 5 out of 5 staff stated that if an incident occurs with the residents, the staff redirect the resident and try to de-escalate the behavior. All staff and ADM stated they document the residents throughout the day, such as their behaviors, ADLs, all cleaning, chores completed, and activities completed. ADM stated if an incident occurs, the Ukeru pads are used when residents are escalating. If a resident sustained an injury that is beyond first aid, the residents are taken to the emergency department (ED). If residents ask to be taken to the ED, staff will either bring them or call the ambulance to transport them. One staff stated residents are checked every 30 – 60 minutes and another staff stated during NOC shift, residents are supposed to be checked on three times during the night, and when the facility door is open, and a loud beeping sound is made.

On 10/10/2022, the Department interviewed 3 residents (R2 - R4). 2 out of 2 residents stated they felt safe living at the facility and one resident did not state whether they felt safe living at the facility; however, the resident stated it was awesome to live in the facility.