Complaint Investigation Report

05/21/2020, and conducted staff interviews on the following dates: 05/29/2020, 06/01/2020, 06/02/2020. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined:

Regarding the allegation “Staff handled client inappropriately:”

It was alleged that during a behavior incident involving Client #1 (C1) that staff utilized a physical intervention inappropriately. LPA conducted interviews with staff and clients, but C1 was unable to be interviewed, as C1 moved out of the facility prior to an in-person interview being conducted. The incident occurred during the overnight shift, which extended from 10:00PM 10/11/2020 to 06:00AM 10/12/2020. Sometime around 11:00PM, C1 entered the kitchen requesting juice from the staff. Staff told C1 they were unable to have juice, either because it was too late at night for juice or there was none of the juice C1 requested in the facility. The response from staff agitated C1 and C1 began verbally engaging with the staff. One staff (Staff #1 – S1) was able to speak to C1 and calm them, offer C1 an alternate drink, and C1 returned to their room. When C1 returned to the kitchen, staff were sitting and laughing, which agitated C1. C1 ran at Staff #2 (S2) and Staff #3 (S3) and Staff #4 (S4) intervened. Witnesses indicated that S2 and S3 pushed C1 against the kitchen counter. S4 then put C1 into a chokehold and S2 held C1’s arms behind their back, resulting in C1 biting S4 in the stomach. S2 and S4 got C1 down to the ground and held C1 while the police were called. Witnesses also indicated that S2 had their knee and bodyweight on C1’s back, while pushing C1 down and holding C1 on the ground. Police report reviewed confirmed that when police arrived at the facility, both S2 and S4 were holding C1 on the ground, with C1’s arms held behind their back. During an interview with police on scene, S4 indicated they “pushed [C1] up against the sink. Staff [S2] grabbed C1’s arms and held them behind C1. Report reviewed indicates police were called at 11:02PM and C1 was arrested at 11:45PM. All staff and witnesses indicated that C1 was held from the time staff called the police until the time police arrived at the facility and handcuffed C1. Additionally, staff interviews revealed that during the incident on 05/18/2020, Staff #5 (S5) placed Client #2 (C2) in a one person hold. Staff #6 (S6), who witnessed the hold, indicated that S5 grabbed both of C2's arms and S5 pushed C2 down into a chair and held C2. Administrator indicated that S5's actions were uncalled for and S5 should never have put C2 in a hold on their own. Therefore, based on interview and record review, the allegation that “staff handled client inappropriately” is deemed SUBSTANTIATED at this time.