| 6400.33(a) | On June 9, 2015 Individuals #1 and #2 were assisting Direct Service Worker #1 with preparations for a picnic supper in the backyard of the home. Direct Service Worker gave Individual #1 a plate with food on it to take outside. Direct Service Worker #1 turned to get a plate of food for Individual #2. In that instant, Individual #2 pushed Individual #1 down the two steps leading from the kitchen to the laundry room. Individual #1's plate tipped and the food fell to the floor. Individual #1 did not fall and was not hurt. Direct Service Worker positioned her/himself between the two individuals. Individual #1 went outside. Individual #2 continued to try to get at Individual #1 but was blocked by Direct Service Worker #1. Direct Service Worker #1 instructed Individual #1 to go into his/her room until Individual #2 could be redirected and was less anxious. Individual #1 went into the living room and sat in a reclining chair and called a family member. Individual #2 came into the home accompanied by Direct Service Worker #1 who continued to attempt to redirect Individual #2. Individual #2 got around Direct Service Worker #1 and hit Individual #1 in the face from behind. Individual #1 had some bleeding from the nose as a result. Individual #1 was examined by ambulance personnel who responded to the 911 call and was later examined at the emergency room. Individual #1 was treated for a facial contusion and released to the home. On July 8, 2015 while eating dinner, Individual #2 began to kick at Individual #1 and then lunged at Individual #1. Direct Service Worker #2 separated the two individuals and Individual #1 went outside. Individual #2 continued to escalate, breaking things, throwing things and hitting and kicking the Direct Service Worker. Direct Service Worker #2 called 911 and the police arrived. Direct Service Worker #2 received authorization from the agency to administer the PRN Lorazepam to Individual #2. At some point between when Direct Service Worker #2 called 911 and when the police arrived, Individual #2 began to calm down. The police informed Individual #2 he/she was not going to the hospital and then left the home. Individual #2 began throwing things. Direct Service Worker #2 went outside to get the police. Individual #2 ran outside where Individual #1 was and pushed her/him down. Direct Service Worker #2 separated the two individuals everyone re-entered the home. The police handcuffed Individual #2 and transported the individual to the hospital. Individual #1 was seated on the recliner chair and was calm. Individual #1 did have a bruise on the left leg. Direct Service Worker checked the bruise but first aid was not needed. According to Individual #1 states "he/she doesn't feel too good when 'Individual #2' gets upset." Individual #1 also stated "he/she feels safe in the home and staff do try to keep her/him safe." | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | Immediately after this incident the CLL Program Director gave staff the directive that when the Individual#1 and Individual#2 were in close proximity to each other that the staff had to be in the same room with them and monitor their interactions at all times. CLL worked closely with Aging Services to ensure that Individual #1 was feeling safe and happy in her home. Individual #1 was interviewed by Aging Services and CLL followed all recommendations by Aging Services. CLL sought out an increase in psychiatric care for Individual #2 including increased visits to her physician. On 7/28/15 CLL requested and received additional staffing to work in the home as Individual #2 continued to show signs of aggression towards her staff and Individual# 1. CLL began providing a 2:2 staff ration on 7/28/2016 to help keep both Individual #1 and Individual #2 safe. During this time the support staff put themselves between Individual#1 and Individual#2 when necessary to protect Individual#1. CLL requested and received a behavior specialist through North West Human Services on 8/26/15. The new behavior specialist did a functional analysis and created a behavior support plan for Individual #2. The behavior plan included strategies to reduce Individual #2's aggression and also help her improve her relationship with her housemate Individual #1. Individual # 2 continued to show aggression towards her housemate and at times needed to be restrained by support staff in order to maintain all individual's safety. CLL conferred with Aging Services, the Behavior Specialist, and Supports Coordinator on a plan of action to separate Individual#1 and Individual#2. The Behavior Specialist felt that Individual #1 was a trigger for Individual #2 and that the relationship may not improve. There was also concern that Individual #1 was no longer feeling safe in her home. At this point Individual #2 requested to move into another residential home within CLL. CLL discussed the move with all support team members including Individual #2's family. On 12/1/15 Individual #2 moved into a new residential home with another female. Another female individual moved in with Individual #1 at the same time. Individual #1's new housemate is not physically aggressive and there have been no issues between them. Individual# 2 has a lot of improvement with her aggression and has never attempted to be physically aggressive with her new housemate at this point in time. The additional staffing is still in place for Individual #2 at her new residence. |
12/01/2015
| Implemented |
| 6400.164(b) | On 7/8/2015 Direct Service Worker #2 administered Lorazepam 0.5 mg PRN to Individual #2. Direct Service Worker #2 did not log this information immediately after the individual received the dose of medication. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The support staff in this situation was retrained on medication administration procedures. The support staff completed the entire Module 5 part of the medication course. The supervisor of the home did two medication observations on the support staff after this incident. The home supervisor reviews the current medication log periodically each month to ensure compliance with medication procedures. This support staff has not had a medication error since this incident. [Within 30 days of receipt of plan of correction, the home supervisor will monitor the medications logs for the individuals in the community homes at least twice monthly. Documentation of the reviews of the medication logs by the home supervisor will be kept and reviewed by the CEO at least monthly to ensure completion and medications are logged immediately after administration. (AS 3/2/16)] |
07/31/2015
| Implemented |