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25 | Licensing Program Analyst (LPA) Alvisoi conducted an unannounced case management inspection, at approximately 9:45am on 12/5/23, and met with Melissa Cardenas- Program's Area Director. Day Services Manager, Shannon Davis, who is covering the Administrator position, was not available on site during the LPA's Inspection.
LPA conducted the case management to obtain more information on client incident reports of 11/20 incident. LPA reviewed client files, which included care plan, and crisis intervention plan; The Mandt technique is part of client's crisis intervention plan. LPA reviewed photos obtained regarding client injury/bruising to hands and wrists.
LPA reviewed staff files, including staff training., S3 is trained in this Mandt technique. LPA conducted interviews, including interviews with day program staff, S1 & S3, regarding the client incident. The staff grabbing/taking both C1's hands and holding them for no more than 10 minutes and letting go, was repeatedly used on 11/20/23 with C1. Per interviews, no calls were made to C1's responsible parties regarding clients behaviors having been escalated from 8am throughout the day at Program.
Per staff interviews, review of incident reports, and information obtained, client was at day program from approximately 8am to 3pm. The client had continued behaviors from the time of arrival to program, which resulted in staff using the Mandt techniques off and on continuously on the client from 8am to at least 2:15pm, when S3 left for the day.
The incident of C1 having behaviors all day at day program, and the continued use of the Mandt techniques by staff, resulted in several bruises to both hands and wrists of the client. Any form of manual restraint should not cause injury to the client. Staff need to be aware of length of time and/or time of continued use of restraint on a client.
Continued on LIC809C... |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/06/2023
Section Cited
CCR
82122(e)(2)
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7 | Emergency Intervention Plan 82122(e)(2) If the staff uses, or it is reasonably foreseeable that the staff will use, manual restraint or seclusion, or both, the licensee shall ensure the time limitations in the Emergency Intervention Plan are adhered to. The Emergency Intervention Plan shall include the following: The use of manual restraint or seclusion, or both, shall not cause injury to the client or others in the program. This requirement was not met as evidenced by: | 1
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7 | CORRECTED- Day Services Manager ensuring a meeting was held with all staff regarding C1's care plan and crisis emergency intervention plan. S3 was provided in-service on Mandt Technique and additional techniques to use in addressing client behaviors. Care plan is continuing to be reviewed per Melissa Cardenas- Program's Area Director. |
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14 | The incident of C1 having behaviors all day on 11/20 from 8am to approximately 2:15pm, and the continued use of the Mandt technique by staff, resulted in several bruises to both hands and wrists of the client. Staff need to be aware of length of time and/or time of continued use of restraint on a client, to not cause injury/resulting in injury. This is a risk to resident's health and safety. | 8
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14 | Program staff met with client's responsible party regarding incident and care plan concerns. Staff will also be updating the care plan regarding meeting client's (C1's) needs, and addressing continued behaviors and incidents as the one occurring on 11/20/23. LPA was provided documents regarding the above. |
Type A
12/06/2023
Section Cited
CCR82072(a)(1)(2)
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7 | Personal rights 82072(a)(1)(2)Each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure that all care staff receive clients personal rights training, ensuring to not violate client rights at any time. Submit proof of training by 12/18/23. Submit plan of correction by12/6/23. |
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14 | The incident of C1 having behaviors all day on 11/20 from 8am to approximately 2:15pm, and the continued use of the Mandt technique by staff, resulted in several bruises to both hands and wrists of the client. Staff need to be aware of length of time and/or time of continued use of restraint on a client, to not cause injury/resulting in injury. This is a risk to resident's personal rights. | 8
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