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32 | • Client Information Sheet • Admission Agreement • Agreements and Consent for Medical Treatment
• Personal Rights • Individual Program Plan (IPP) • Behavior Consultant Notes • Special Incident Reports
• Hospital/Medical Reports • Facility Client Notes • Body Assessment Sheet • Staff Roster • Client Roster • On-The-Job Training job for S1 and S1 • CPI Certificates for S1 and S2
The investigation revealed the following;
Allegations: Resident was not allowed to have a snack and Staff restrained resident. The details of these allegations state that on 11/5/21, at 5am, C1 asked for a snack from S2 because he felt hungry and S2 denied him snacks which caused C1 to get upset and attack S2. AS a result, staff placed him on a CPI hold.
Based on interviews conducted, the statements obtained were consistent and corroborated with these allegations. During the interview of C1, C1 stated that on the morning of 11/5/21, he asked S2 to warm up his left-over food from the night before but S2 refused and told him to go back to his room which made him upset and as a result he attacked S2. S1 and S2 than placed C1 on a CPI hold. Interviews conducted of the Administrator and S1 confirmed that the incident was a result of S2 refusing to serve a meal to C1, on the morning of 11/5/21, at 5am. After the incident, the Assistant Administrator conducted an in-service training with staff on the importance of having the kitchen open for clients, regardless of time of day. During the visit conducted on 11/22/21, the Assistant Administrator was unable to provide documentation if a debriefing session was held within 24 hours after C1 was placed on a CPI hold on 11/5/21. The purpose of the debriefing session is to help assess whether the intervention was necessary and was implemented in a manner consistent with staff training and facility policies. As required by Section 1180.5(d), debriefings must be documented by facility staff in the client’s record and must document any changes to the needs and services or treatment plan as a result. The SGPRC also conducted an investigation and the following recommendations were made;
• Ensure to Complete an in-service regarding Client Rights Training – interviews indicate the incident began after C1 was told that he could not microwave his food at 5am because it was “too early” in the morning and other residents were still sleeping.
• Ensure CPI training for S1 and S2. Interviews indicate that S2 placed his arm diagonally across C1’s chest/waist area as they both sat on his bed. S2 explained that placing his arm across C1’s chest/waist area (like a seat belt) was to ensure that he did not “go after” S1 as she was collecting C1’s belongings. An Arm placed across an individual’s chest area is not a certified CPI technique. Also, it does not appear that |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/16/2023
Section Cited
CCR
80072(a)(3) | 1
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7 | Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. | 1
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7 | Administrator will review Title 22 Regulations, Section 80072 on Personal Rights, and conduct an in-service training with all staff on the importance of client personal rights. Administrator will submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training. POC is due to CCL by 6/16/23. |
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14 | This requirement is not met as evidenced by: Based on interviews conducted, the statements obtained were consistent and corroborated that on the morning of 11/5/21, at 5am, C1 asked S2 to warm up his left-over food from the night before but S2 refused and told him to go back to his room which made him upset and as a result he attacked S2. Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
06/16/2023
Section Cited
HSC
1180-1180.6 | 1
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7 | California H&S Code 1180-1180.6 sets forth guidelines to be adhered to; prior to, during, and after the use of restraints or seclusion of facility clientele.
This requirement is not met as evidenced by: S1 and S2 failed to follow proper procedures and documentation was not found for quality | 1
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7 | The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California H&S Code 1180-1180.6. POC is due to CCL by the POC due date of 6/16/23. |
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14 | review, debriefing not completed. Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. | 8
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