Here is pertinent text from the Statement of Deficiencies regarding the client abuse incident of 12/23/2009 (from
V500,
V512,
V522,
V537, my apologies if I've missed some stuff):
From V 500 · 27D .0101(a-e) Client Rights - Policy on Rights:
Based on review of facility records, and interviews, the facility failed to implement their policy requiring and ensuring the Department of Social Services (DSS), in the county where services are provided, was notified of all allegations of resident abuse by health care personnel, affecting one of four sampled clients (#4). The findings are:
A review of facility records on 3/1/10 revealed an incident report dated 12/23/09 and 2 incident reports dated 12/24/09 addressing a restraint of Client #4 which occurred on 12/23/09. The report by the Facility Manager dated 12/23/09 stated he "restrained (Client #4) to ground and held until staff intervened." The attached Physical Intervention report also completed by the Facility Manager on 12/23/09 revealed, in the section asking if the student was injured during the intervention, Client #4 got a "bloody lip trying to bite staff."
Review on 3/1/10 of the 2 incident reports completed 12/24/09 revealed Staff #1 and Staff #2 witnessed the Facility Manager strike Client #4 during the restraint on 12/23/09. The incident report by Staff #1 revealed he "saw
[the Facility Manager] hit [Client #4] in the face ... and observed [Client#4] had blood in his mouth." The incident report by Staff #2 revealed the Facility Manager "took student to ground and punched [Client #4] in the lip."
A review on 3/1/10 of an internal investigation report revealed the Executive Director(ED) was out of town and learned of allegations by Client #4 and Staff #1 and #2 in a phone call from the Admissions Director(AD) on 12/23/09. The AD was in charge of facility in the absence of the ED. The AD documented an interview at approximately 4:30 PM on 12/23/09 with Client #4, during which Client #4 told him he had hit the Facility Manager in the face and the Facility Manager hit him back in the face.
Review on 3/1/10 of facility policy and procedures for reporting allegations of abuse revealed: "Policy: The therapist shall provide a leadership role in the identification, reporting, and follow-upon child abuse issues. ... Procedures: ...3. The therapist will receive supervision from a clinical supervisor and the Executive Director to determine if there is enough data to warrant a "reasonable suspicion" that a student has been the victim of abuse. That is all that is required for a suspected report. ... 6. c. Documentation will be made on the Abuse, Neglect, and Dependency Report, Attachment 2 and will be forwarded to the Department of Social Services (DSS)."
Review of facility records on 3/1/10 revealed no Abuse, Neglect, and Dependency Report, Attachment 2 was on file, nor was there documentation that such a report had been forwarded to DSS.
Interviews with Staff #1 and the Facility Manager on 2/26/10, and with Staff #2 on 3/4/10, confirmed that the Facility Manager actively participated in the restraint of Client #4 on 12/23/09, and that Client #4 was injured as a result of the Facility Manager's participation. The Facility manager admitted to punching Client #4 in the face, and both Staff #1 and Staff #2 revealed their belief that the punch was intentional, and not accidental.
During interviews with the Executive Director and Human Resources Manager on 2/26/10 and 3/1/10, staff were asked to locate and provide documentation of any in-house investigation or other documentation pertaining to the restraint of Client #4 on 12/23/09. Staff were able to produce incident reports regarding the incident, a summary of the AD's interview with Client #4 on 12/23/09, and a timeline documenting the ED's contacts along with a brief summary of those contacts regarding the 12/23/09 incident. Staff failed to provide verification of an in-house investigation, other than the interview with Client #4, and were unable to produce the Abuse, Neglect, and Dependency Report, Attachment 2. Staff also acknowledged no report had been filed with DSS, nor had a report been filed with the Health Care Personnel Registry.[/list]
From V 512 · 27D .0304 Client Rights - Harm, Abuse, Neglect:
Based on record review and interviews, facility staff failed to protect 1 of 4 clients audited from abuse (#4). The findings are:
Review of client records on 2/26/10 revealed Client #4 was admitted to the facility on 9/19/09, with diagnoses of Bipolar Disorder, Disruptive Behavior Disorder, and Intermittent Explosive Anger Disorder. Review further revealed, Client #4 graduated from the program on 1/13/10.
Review of staff records on 2/26/10 revealed the Facility Manager was hired 4/1/08. Review further revealed, his Crisis Prevention Intervention (CPI) training was effective 1/10 through 1/11.
Review on 2/25/10 of incident reports dated 12/24/09 revealed the following:
1) Staff #1's incident report stated: "Client #4 grabbed the rope from Staff #2 and refused to let go. Client #4 then began to kick Staff #2 in the legs, bit and punched him (Staff #2) in the face and body. The Facility Manager attempted to verbally de-escalate Client #4 but was unsuccessful. Client #4 was taken to the ground by the Facility Manager and was assisted by Staff #1 and #2. Client #4 was released and immediately attacked the Facility Manager again. The facility Manager "took student (Client #4) to ground and punched
[Client #4] in the lip." Staff #1 and #2 joined in a hold a second time. Client #4 was released a second time. Client #4 approached the Facility Manager a third time and continued to punch and kick. The Facility Manager attempted verbal de-escalation again and took Client #4 to the ground. Client #4 was released almost immediately."
2) Staff #2's incident report stated: "...Group was dropping near bear hang when [Client #4] refused to give bear rope to staff [Staff #1] and threatened to hit [Staff #1] in the face if he took it. [Staff #1] told student that he needed to take rope. [Client #4] then hit [Staff #1] in the face and continued a physical attack hitting, kicking, and biting [Staff #2]. [Staff #2] used deflection to avoid injury and tried to verbally de-escalate the situation. Staff [Facility Manager] was walking by and tried to verbally de-escalate student [Client #4]. [Client #4] said it was none of [Facility Manager] business and if he didn't leave then he [Client #4] would hit and kick [Facility Manager] was well. [Facility Manager] said he would not leave and that [Client #4] could not hurt staff at which time [Client #4] stopped hitting staff and began to kick and hit staff [Facility Manager]. [Facility Manager] told [Client #4] to stop hitting and kicking and when [Client #4] did not [Facility Manager] layed hands on [Client #4] grabbing his collar and lowering him to the ground. The time was 4:30 PM. Staff [Staff #2] intervened to separate staff and student taking control of student [Client #4's] legs to keep staff [Facility Manager] from getting kicked. [Staff #2] immediately called staff [Staff #1] to take control of [Client #4's] legs to allow him [Staff #2] to control [Client #4's] upper body to release staff [Facility Manager]. Staff [Facility Manager] did not release control so [Staff #2] called for a release. All staff released control. [Client #4] then continued to attack staff [Facility Manager] hitting and kicking. Staff [Staff #2] had called for support on the radio at 4:45 PM. Staff [Facility Manager] grabbed student [Client #4] by the collar of his shirt and quickly lowered him to the ground. Staff [Staff #2] attempted to intervene with staff [Staff #1] when [Staff #2] saw [Facility Manager] hit [Client #4] in the face after being hit by [Client #4]. [Staff #2] took control of [Client #4] with [Staff #1] assisting and observed that [Client #4] had blood in his mouth. Support showed up at this time. All staff released control of [Client #4]. [Client #4] then began to follow staff [Facility Manager] and attempt to assault him. The time was 5:15 PM. [Facility Manager] took [Client #4] by the shirt front again and pushed him to the ground, and then released him..."
3) The Facility Manager's incident report dated 12/23/09 reported: "Observed student (Client #4) yelling kicking and punching staff. Went to observe and try to defuse the situation. Client turned on me with verbal, kicking punching and biting." The intervention used included "Restrained to ground and held until staff intervened."
Review on 2/25/10 of Facility Managers physical intervention report dated 12/23/09 revealed the following:
a) Behavior That Necessitated the Physical Intervention: "Punching and kicking staff- verbal abuse."
b) Positive and Less Restrictive Alternatives Used or Considered: "Talking and reasoning."
c) What Danger Necessitated the Intervention? "Several punches and kick."
d) Precipitating Factors of the Intervention: "Escalated student assaulting 2 staff."
e) Was The Student Injured During the Physical Intervention? "Yes. Bloody lip trying to bite staff."
f) Description of Plan to Minimize Future Physical Interventions: Minimize contact and ask for support in situations."
Review on 2/25/10 of the Director of Admissions investigative report dated 12/23/09 revealed the following: "...According to [Client #4], {Staff #2] was making his life difficult with the bear bag ropes and so he decided to kick him. [Staff #2] asked him to stop and he did not and walked off. [Client #4] reported that [Staff #2] tackled him and was holding him down, so in defense, he began hitting him. [Staff #2] then was holding him down and so [Client #4] continued to kick him and get him to give him the rope. [Facility Manager] came down from cabin 1 and told [Client #4] to stop hitting [Staff #2]. [Client #4] told him (Facility Manager) that it was none of his business and that he would do what he wanted. He (Client #4) kept hitting and punching [Staff #2] and [Facility Manager] intervened and restrained him. [Client #4] reports that when he got back up that he went after [Facility Manager] many times and [Facility Manager] restrained him again. [Staff #2] at this point had his legs. He (client #4) said that he went after [Facility Manager] in frustration and hit him in the face and that [Facility Manager] hit him back in the face."
Record review on 2/26/10 revealed, neither a 24 Hour Initial Report nor a 5-Working Day Report to Health Care Personnel Registry (HCPR) had been completed.
Interview with Staff #1 on 2/25/10 revealed, there were teeth marks in Client #4's lip. "He bit his lip when he was hit (by the facility manager)." Interview further revealed Client #4's injury was the result of the hit. Interview further revealed, the facility manager did not utilize approved restrictive intervention techniques.
Interview with Staff #2 on 3/4/10 revealed, he witnessed the facility manager punch Client #4 in the mouth. "He (facility manager) was pushing him (Client #4) at the same time and popped him, he did not wind up and clock him." Interview further revealed, Client #4 had a bloody lip which was associated with the hit. Interview further revealed, the facility manager did not utilize approved restrictive intervention techniques. "He (facility manager) pushed him (Client #4) down by the shirt...there was force but it wasn't a slam to the ground."
Interview with the facility manager on 3/1/10 revealed, "I grabbed him (Client #4) by the shirt and put him down...[Staff #1] and [Staff #2] grabbed his (Client #4) feet. [Staff #1] let go of his (Client #4) right hand and I took one right on the nose. I popped him (Client #4)...light fist on the chin. It's really bothered me ever since, I liked the kid."
Client #4 was unable to be interviewed. He was no longer at the facility.
Interview with the Executive Director on 2/25/10 revealed, "My understanding is [facility manager] struck [Client #4]. [Facility manager] confirmed this."
During interview with the Executive Director on 3/4/10, she acknowledged Client #4's parents were contacted and no other authorities were informed of the incident. Interview further revealed, the facility sought clinical consultation about the incident and were told it was unnecessary to contact Department of Social Services and HCPR due to it not meeting the criteria for abuse.
A protection plan was completed by the facility on 3/4/10, which included the following:
"1. All Trails personnel who have any interaction with Trails clients will have restrictive intervention training."
"2. All Trails staff whether direct care or support will have training on a typical client profile and types of behaviors to expect."
"3. Employee evaluations will include a section on interactions with Trails students."
"4. Trails will review with all staff protocols for reporting a staff if they believe that there has been any interaction they deem appropriate or demeaning. Identified staff member will then review the incident and take appropriate disciplinary action."
(This deficiency constitutes a Type B rule violation. An administrative penalty of $200.00 is per day will be imposed for failure to correct within 45 days.)[/list]
From V 522 · 27E .0104(e10) Client Rights - Sec. Rest. & ITO:
Based on record review and interviews, the facility failed to ensure interventions exceeding 15 minutes were authorized only by the responsible professional or another qualified professional who is approved to use and to authorize the use of the restrictive intervention based on experience and training, effecting 1 of 4 clients audited (#4). The findings are:
Review of Physical Restraint Reports on 3/1/10 revealed the following physical restraints of Client #4 which exceeded 15 minutes:
9/19/09 at 7:30 PM for 30 minutes
9/20/09 at 4:00 PM for 30 minutes
9/20/09 at 5:50 PM for 48 minutes
9/22/09 at 8:30 PM for 45 minutes
9/23/09 at 12:15 PM for 30 minutes
9/23/09 at 1:00 PM for 30 minutes
9/29/09 at 4:10 PM for 20 minutes
1/15/10 at 5:11 PM for 28 minutes, and 34 seconds.
The review further revealed no documentation on the Physical Restraint Reports or on file elsewhere of authorization for restraints lasting longer than 15 minutes by the responsible professional (QP) or another qualified professional who is approved to use and to authorize the use of the restrictive intervention based on experience and training.
During interview with the Executive Director (ED) on 3/4/10, The ED was asked to locate and produce verification of authorization by a QP for physical restraints exceeding 15 minutes in length. She was unable to provide the requested verification. The ED acknowledged that staff were not seeking authorization from the QP for extended restraints.
From V 537 · 27E .0108 Client Rights - Training in Sec Rest & ITO:
Based on record review and interviews, the facility failed to ensure physical restraint was employed only by staff who had been trained and had demonstrated competence in the proper use of and alternatives to these procedures, and were retrained and had demonstrated competence at least annually, effecting 1 of 4 client's audited (#4). The findings are.
A review of policy and procedures on 2/26/10 revealed the facility staff utilize the Crisis Prevention Intervention (CPI) system for employing physical restraints, and that physical restraints may be employed on an emergency basis, when a client provides a danger to himself or others, and inflicts significant property damage.
A review of incident reports on 3/1/10 revealed 3 incident reports describing the Facility Manager taking Client #4 to the ground twice during a single incident at approximately 4:30 PM on 12/23/09. Client #4 received a cut in his mouth as a result of a punch by the Facility Manager during the physical restraint. Further review of the incident reports also revealed the Facility Manager took the client down by"grabbing his collar and lowering him to the ground."
A review of staff personnel records on 3/1/10 revealed no evidence on file that the facility manager had participated and demonstrated competence in CPI Training between his hire date of 4/1/08 and January, 2010.
During interviews with staff conducted on 2/26/10 and 3/4/10, administrative staff were asked to locate and provide verification of training within a year prior to the 12/23/09 incident in CPI for the Facility Manager. Staff were unable to produce verification of the required training for the Facility Manager.
Interviews with Staff #1 and the Facility Manager on 2/26/10, and with Staff #2 on 3/4/10, confirmed that the Facility Manager actively participated in the restraint of Client #4 on 12/23/09, and that Client #4 was injured as a result of the Facility Manager's participation.The interview with the Facility Manager on 2/26/10 also revealed that the Facility Manager had received NCI training from a previous employer, but he was not current in any kind of restraint training at the time of the incident.
