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- Dual (Complaint)
- Licensing received an email from a former employee, who quit due to a “continuing refusal by upper management to report incidents as required.” Complainant reported a specific incident on 9/25/22, in which a CNA took a resident down to the floor in what appeared to be a “very inappropriate restraint” after being assaulted by resident. The resident and CNA both sustained superficial scratches. After video footage was reviewed, the CEO determined there to be no need to report the incident. Complainant disagreed and submitted a letter of resignation, stating “I could no longer continue in a position I felt was making me compromise my values and fight my superiors almost daily. This has been an on-going issue since day 1.”
- Licensing follow-up: Licensing was informed the CNA involved is no longer employed with facility, and the facility will no longer use Shift Key (an outside contractor). Camera footage was reviewed on 10/03/22 and showed staff out of ratio on the green unit on 9/25/22 (1:10). Staff approached client after client threw crackers at staff, at which point client punched staff. Staff attacked client and placed her arm around client’s neck and slammed her to the ground. Other staff entered unit while staff and client were on the floor. Staff could be seen laying across the client’s mid-section of her body. Referral #2169574 was screened out. Outcome: Founded.
- Licensing cited facility for the following:
- R109.1.g – Staff engaged in unprofessional conduct that can be viewed as physically harmful to a resident.
- R905.9 – Staff did not use the minimal force or time necessary during the restraint hold.
- R907.3 – Staff was out of ratio 10:1 on the green unit.
- R110.9 – Facility failed to report to the child abuse hotline.
- R105.3 – Staff did not receive preservice training before being counted in staff/child ratio.
- R105.7 – Staff participated in a restraint hold of a resident prior to being trained in SAMA.
- R103.1 – Staff did not have all the required background checks conducted before working on the floor with residents.
