Complaint Investigation Report

Staff 2 (S2) turned the computer screen off and said they could come in thinking it would lock itself. C1 then tried to access the computer, turned on the screen and was able to browse the internet. S1 and S2 tried to redirect C1 off the computer but were unable to. A few minutes later, S1 unplugged the computer to stop access and C1 charged out of the room and destroyed property. Staff interviewed revealed that this happened a few days before as well and staff were able to turn off the computer and there was no behavior. Therefore, they thought it would work again this time. C1 was issued an immediate termination and asked to not come back to the day program. The immediate termination will be addressed in Case Management Visit.

LPA reviewed C1’s file which states there have been challenges regarding behavioral episodes resulting in injury to staff and C1. The team are working together to address the challenges and maintain a happy and safe environment for C1. Family provided helpful insight for supporting C1 and has been doing well since, having only 2 minor incidents where C1 was easily redirected. “Going forward we plan to discuss the possibility of behavioral services to create a behavior plan for C1 at Day Program.”

A Family Member (FM) stated there was a behavior plan put in place where C1 was assigned a 1-to-1, offices would be locked, computers would have passwords, and there would be an internet free area for C1. FM stated C1 gained access to the internet twice prior to this meeting and twice following the meeting and the facility did not implement the plan. Family Member stated if staff would have followed the plan and locked their computer prior to C1 coming into their office, this would have never occurred.

Administrator stated they could never guarantee C1 won’t gain access to a device or computer, stating their program isn’t made that way. Administrator stated their computers and iPad’s have a password for login and will sleep and lock after 60 minutes. LPA suggested facility conduct a training on how staff should lock their computer properly and decrease the time to 15 minutes.

LPA interviewed C1’s Service Coordinator and Behaviorist who stated that the facility had a plan in place establishing particular rooms would remain locked to prevent C1 from accessing electronic devices as well as adding a password to devices to restrict access to C1. Behaviorist stated C1’s primary 1-on-1 should have followed C1 out of the room on May 5, instead of C1's backup 1-on-1 and may have been more successful at de-escalating C1. Behaviorist stated C1’s primary 1-on-1 had the most training and experience with C1 and should have been with C1 when they left the room. The facility did not provide adequate supervision by not properly implementing C1’s behavior plan therefore, not meeting C1’s needs by allowing C1 to gain access to a computer on 2 occasions. Based on the information obtained, the allegation is Substantiated at this time. Exit interview completed, copy of report and appeal rights were issued.