ELLNER TERRACE Facility I.D. Number 0036327 Date of Survey: 02/22/02 Complaint Investigation "A" VIOLATION(S): The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served. The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the administrator. The policies shall be available to the staff, residents and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually. There shall be available sufficient, appropriately qualified training and habilitation personnel, and necessary supporting staff, to carry out the training and habilitation program. Supervision of delivery of training and habilitation services shall be the responsibility of a person who is a Qualified Mental Retardation Professional. Appropriately qualified staff shall be provided in sufficient numbers to meet the training and habilitation needs of the residents. At a minimum, staffing shall be provided as described in Section 350.810(b) of this Part. An ongoing resident record including progression toward and regression from established resident goals shall be maintained. The records of residents participating in training and habilitation programs shall document the appropriateness of the program for the resident and the resident’s response to the program, as described in Section 350.1060(i) of this Part. NO RESIDENT SHALL BE DEPRIVED OF ANY RIGHTS, BENEFITS, OR PRIVILEGES GUARANTEED BY LAW BASED ON THEIR STATUS AS A RESIDENT OF A FACILITY. (SECTION 2-101 OF THE ACT) AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act) RESIDENT AS PERPETRATOR OF ABUSE. WHEN AN INVESTIGATION OF A REPORT OF SUSPECTED ABUSE OF A RESIDENT INDICATES, BASED UPON CREDIBLE EVIDENCE, THAT ANOTHER RESIDENT OF THE LONG-TERM CARE FACILITY IS THE PERPETRATOR OF THE ABUSE, THAT RESIDENT’S CONDITION SHALL BE IMMEDIATELY EVALUATED TO DETERMINE THE MOST SUITABLE THERAPY AND PLACEMENT FOR THE RESIDENT, CONSIDERING THE SAFETY OF THAT RESIDENT AS WELL AS THE SAFETY OF OTHER RESIDENTS AND EMPLOYEES OF THE FACILITY. (Section 3-612 of the Act) Based on interview, review of behavior and incident reports and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the clients for 14 of 15 clients (R. 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15) who were subjected to physical and psychological abuse by one client (R3). Findings include: The facility neglected to provide services necessary to avoid physical and psychological harm to clients as a result of R3's physical and verbal aggression and from harassment and intimidation inflicted on staff and clients by R3. 1) Clients interviewed indicated fear of R3 since he moved to the facility 6-5-01. R3 is a 20 year old male with a diagnosis of Mild Mental Retardation (IQ of 61), ADHD, and intermittent explosive disorder. Other diagnosis noted throughout the clinical record include Depression, Impulse Control Disorder. R3 was admitted to the facility from a psychiatric hospitalization following discharge from another group home due to physical aggression and due to threatening staff with a knife. The psychological report dated 11-28-00 states R3 has had a long history of residential living / hospitalizations "because of uncontrollable anger and unmanageable aggression." The report further states that R3 had a history of attempting to steal a car (although he did not know how to drive) and at age 12 sexually molesting a 10 year old peer. The report states R3 made inappropriate sexual remarks to the staff "have been problematic. In addition, 'hurts self / disruptive / socially offensive / uncooperative' are indicated to be 'critical' problem areas." A social service consultation dated 6-29-01 (after R3's admission to the facility) states R3 tried to steal a car on 11-28-00 when he was arrested. The report says R3 has had a history of uncontrollable anger and unmanageable aggression and states the facility does "need to look at, should R3's behaviors continue, whether this setting is a good fit for R3's needs." The reports indicate a long mental health history and he has been a ward of DCFS since childhood. R3 was hospitalized 7-01, and 11-01 for aggression. Since admission to the facility, the following aggressive behaviors have been documented: On 8-3-01 R3 held a peer's head under the water at a pool and choked him. On 9-29-01 R3 grabbed another resident by the neck at the facility. On 10-18-01 R3 threatened a staff to "stomp the s--- out of you", then hit the staff in the leg several times, then grabbed the staff by the neck leaving red marks on her neck. R3 then reported the staff pulled hard on his hand. On 10-31-01 R3 went to hit a peer at workshop. Staff intervened to stop him. On 10-31-01 R3 tickled a peer at the workshop until the client fell backwards off the picnic table. On 11-1-01 R3 got in a peer's face and threatened him then told staff he would pick up an exercise machine to hit the staff with it. On 11-4-01 R3 threatened to break car windows at the facility. On 11-4-01 R3 was yelling and slamming doors and giving an obscene hand gesture to staff and peers. On 11-7-01 R3 threatened to punch a staff in the face because he did not have a lighter to give to R3 then continued to curse and yell On 12-18-01 R3 threatened to bring a knife to the workshop and "slice one of the staff". On 12-19-01 R3 took a client's wheelchair to sit in and was non-compliant with returning the wheelchair. On 1-17-02 R3 was in a rage because he was not allowed to go to church due to behaviors and tried to cut his wrist with a scissors, pulled decorations down, slapped a client, threatened staff with "I will snap your neck", going into other resident's rooms, threatening other residents, punched a resident's TV, yelling to "get out of my f------ way", kicking doors. On 1-29-02 R3 picked up a resident by his arms and tried to flip him over his back. On 1-29-02 R3 chased a male resident down the hall. On 1-29-02 R3 grabbed a staff member's wrist with 2 hands - twisting in opposite directions to cause a sprain. In addition, R8 said R3 put his hands around his neck and choked him. R10 reported that R3 punched her in the arm, but staff were not aware of the incident. R1 stated in interview on 2-1-02 that R3 has hit him and picked up a chair to throw at him and in November (2001) R3 came after him with a screwdriver and the police were called. R1 said he did not think R3 would be back after that incident, but he was readmitted to the facility. This was verified by Z3 interview per phone on 2-1-02 at 4:40 PM, police have been called to the facility several times due to R3's uncontrollable behavior: Police were called to facility on 7-10-01 from 5 - 5:30 PM due to staff R3's unruly behavior and staff being unable to control. Police were called to facility on 11-9-01 from 10:00 - 10:30 PM - staff unable to control R3. Police were called to facility on 11-14-01 from 8:10 - 8:45 PM R3 was combative and was transferred to hospital for psychiatric evaluation. Officer "assured by administrator that resident would not be back to this facility - R3". Police were called to facility on 1-29-02 from 8 PM - 9:30 PM when staff assaulted by R3. Staff required medical care following a wrist injury inflicted by R3. Per Z3, the clients at the facility are fearful of R3 as evidenced by R11 crying and all other clients were there and afraid. Z3 said since 1994 when he assumed his position, he has never seen another client who posed more of a threat to the staff or clients and felt it would only be a matter of time until someone would be badly hurt. Z3 said usually R3 would respond to him and calm down when he came to the facility as a policeman, but on 1-29-02 when he assaulted the staff, R3 would not calm down and "acted like he was going to come after me next. When I told him I would pepper spray him, he stopped and started to calm down." Z3 said when R3 became violent, he was uncontrollable and felt management was ignoring the situation or staff were not reporting the incidents to upper management. 2) The following clients all expressed fear of R3 or took precautions to avoid contact with him due aggression: a) R1 per interview at workshop on 2-1-02 - R3 threatened to throw a chair at me. I went to my room and staff told all clients to go to their room. R3 has hit me and put his fist in my face. He came after me with a screwdriver. He has hurt the staff. "If they don't get him out of here, he's going to hurt somebody real bad." R1 said R12 was my roommate and R3 kept coming after him. R12 had scratches on him as a result of being so upset from R3. Per R1, staff moved R12 to a different room to protect him from R3. R1 said he did not trust R3 and he stayed in his room a lot due to R3. R1 said, "I am not a loner, but I stay in my room to stay out of his way. I don't want trouble. I used to be out of my room more." R1 said on the morning of 2-1-02, R3 went after R2 after he got mad at R2. R3's fist was up, but according to R1, R3 finally backed off. He did not know if staff were aware of the situation. R1 said there was one cook and 1 direct care staff for bathing and meds in the morning. b) Interview with R12 at the facility on 1-29-02 revealed R12 is afraid of R3. R12 said he had lived at the facility since 1989 and has not been afraid to live at the facility until R3 was admitted. R12 said he has had to take something for his nerves since R3 came to the facility. (This was verified by clinical record showing medication increases and changes due to increased anxiety since R3 was admitted to the facility). Per R12, R3 teases him, laughs at him, had come in his room and knocked his pictures and TV down. R3 came after him with a belt and he was locked in the kitchen with other clients for 3 ½ hours to protect him from R3. R12 said his father knows about the situation and R12 asked his father to move him out. R12 said, "I think I may go bonkers because of him (R3)." It was verified by Z1 per phone interview that R12 begged him to take him home due to R3's behaviors. Per Z1, the administrator told him that R3 was only looking for cigarettes when he went into rooms. Z1 stated he felt administration was neglecting to take action to protect the clients. Interview with E13 per phone revealed he had talked to staff on the evening of 1-17-02 when staff had clients locked in the kitchen for protection from R3 and told the staff to give R3 a cigarette - that he would calm down if a cigarette was given. There is no evidence other intervention was taken to prevent individuals from creating an environment of fear. c) R4 said in interview at facility 1-29-02 that R3 laughs at him and teases him. He has not threatened him lately. R4 said he was locked in the kitchen to protect him from R3. R4 said R3 will fight and hurt the clients and staff - that R3 will yell and hit the walls. R4 said he is afraid of R3 and goes to his room to get away from R3. R4 said R3 will go into his room and go through his things. d) Interview with R8 at the facility on 1-29-02 revealed he was admitted to the facility last summer. Resident roster indicated he was admitted to the facility on 7-1-01. R8 said he was letting R3 play his video game and when R8 tried to explain how to play the game to R3, R3 grabbed him by the neck and choked him. R8 said R3 tries to come into his room, but he is not allowed to. When R8 was playing baseball outside with R3, R3 became angry and came after him. R8 said he would have nothing to do with him unless made to because he cannot be trusted. "One minute he is nice - then turns around and is not nice - he yells." R8 said he is not afraid of R3 because he can take care of himself, but said R12 is frightened of R3. R12 had been roommates with R8, per R8, but was moved across the hall to be further away from R3's room due to R3's harassment. R8 said on the previous week-end, R3 kept putting his nose to clients' buttocks and "sniffing everyone's butt." This was verified by a behavior report. R8 said E1 knows about the situation - that he has talked to her about it and she said she would talk to R3. e) Interview with R10 at the workshop on 2-1-02 revealed she is afraid of R3. R10 is a small stature female slightly built female and R3 weighs more than 200 lbs. R10 said R3 sticks his finger in her face and threatens to hit her. She said she tries to stay away from him and tries not to go by him. R10 said over the week-end R3 held E5 by the wrist and hurt her. She said the previous Wednesday, R3 "punched me in the arm." R10 said she has seen R3 hit R7 and one time he hit R7 on the head with a box of candy. R10 said R7 cannot defend herself. R10 said R12 is afraid of R3 and that R3 tried to hurt R12, but E2 protected him. I was afraid and was locked in the kitchen with E2 with R12 and R4 and R11. R3 kept kicking the doors, yelling cursing and kept trying to get in the kitchen "to get us". R10 said E1 did not talk to her about the incident to ask if she was afraid or to find out facts of why she was locked in the kitchen for protection. 3) The facility neglected to ensure there were monitoring systems to prevent such incidents of physical and psychological harm. Clients were placed in an environment with an aggressive / assaultive client, and the facility neglected to provide adequate supervision and staff to prevent such incidents. Interview with R3 at the facility on 1-29-02 revealed he has full knowledge of what he is doing when he intimidates, abuses and harasses staff and clients. R3 said when he gets mad, he hits the wall, cusses at staff, yells and at times threatens to kill them. R3 said he went into R12's room and got in his face, backed him into a corner and threatened him with a belt. R3 said he "scares clients because I think it is fun." R3 said he left his previous placement because he threatened and scared staff with a knife. R3 said he tried to throw a chair at a client and went after him with a screwdriver - police were called. R3 knew he took Zyprexa and Depakote for behavior. R3 said he choked a client and E7 before. This was verified by E7 who said R3 choked him with a necklace R7 was wearing. R3 said he was going to hit staff. R3 said he threatens and raises his voice - sometimes he "wants to scare them." R3 said he liked the people to give him all the attention and said he gets upset if he is ignored. 4) There was evidence of psychological and physical abuse and the facility neglected to revise active treatment strategies to protect individuals from the abuse. Following R3's hospitalization for psychiatric evaluation 11-14-01 after threatening a client with a screwdriver and throwing chairs, no revisions were made in R3's programs or environment. There was no increase of staff to ensure closer monitoring of R3. There was no change in R3's programs or active treatment plan to ensure a safe environment for other clients. On 1-17-02, per behavior reporting form, from 6:30 PM ongoing for at least 3 ½ - 4 hours, R 3 demonstrated the following maladaptive behaviors: "tried to cut wrist with scissors, pulling decorations down, slapping another resident, tripped staff, calling staff names like 'B---- ", threatening them like "I will snap your neck', threw Bible down and yelling, cursing, slammed door, going in other residents' rooms and threatening to break stuff and punch a resident's TV, threatening other residents, made another resident cry and was really shook up, throwing napkin at staff and resident repeatedly and saying he is going to run off (then attempting to), yelling at residents (saying shut up and get out of my f------ way' punched door." The report said he wanted to go to church but was not allowed to because of behaviors and redirection to go to his room and listen to radio or draw was unsuccessful. Per interview with E3 and R12, R3 was threatening R12 with a belt. The written report did not specifically say this, but per interview, R3 was in R12's room threatening to kill him and swinging a belt. Per interview with E3 at the facility on 1-29-02, R12 was pinned in his room by the window with R3 at the door and R3 was swinging a belt. E3 said they (staff) got R12 out of the room and removed clients from the area. R3 kept coming after R12 and they (staff) put R12 , R10, R4 and R11 in the kitchen with staff for protection from R3. Per E3, R12 was shaking, and R10 was crying from fear. E3 said phone conference with E1 and E3 resulted in advice to give R3 a cigarette. E3 said they were not to call police. E3 said R3 also swung a wood bat and threw soiled facial tissue in resident's faces. E3 said R3 seemed to "get high" from the aggression. E3 said R3 targets female staff and goes after young staff and a female staff had to be locked in the med room for protection from R3. E3 said the behaviors are unpredictable and explosive - such as when a ball came too close to him while playing ball with a peer. He called the peer a moron and retarded. He barked loudly into a client's ear and scared her. He tried to aggressively tickle a non-verbal, profoundly retarded, small male client who chooses to sit in a fetal position in the living room. E3 said the staff were on their own and no changes in staff or programing had been done to deal with R3's behaviors and no additional staff training had occurred to deal with R3's behaviors and to ensure the safety of clients. E1 said the staff were to remove R3 from the environment when he was raging. E1 said R3 should go outside for physical activity. This is not incorporated into the behavior plan and there is no alternative if there is inclement weather or if there was only one - 2 staff available at the facility to deal with the maladaptive behaviors. E7 said in interview at facility on 2-1-02 that R3 dominates clients or females / staff who are weaker than he is. R3 also demonstrates inappropriate sexual behavior such as making "humping movements on the floor in front of clients" and asking R9 if she wants to have his babies. E7 said he saw R3 in R14's room when R14 was in bed and awake. R3 had his fist in R14's face. E7 said he wrote a report on the incident, but R3 denied the incident. Z5 said in interview at the workshop that clients are afraid of R3, and he picks on those who are weaker than he and he lies - especially when he is wrong. E1 and Z1 said R3 will lie and manipulate to his advantage. Interview with Z4 per phone on 2-1-02 that R3 is hospitalized when he is aggressive and must earn his way back to the group home but admitted he always has good behavior in the hospital because it is a more restrictive setting. Z4 said R3 gets negative attention when people are afraid of him, and he cannot always control his impulses and aggression. Z4 said R3 may be able to learn more appropriate behavior in a more controlled setting. Interview with Z6 per phone on 2-13-02 revealed after the last staff injury caused by R3, that she recommended R3 be moved to a more secure environment. Z6 said there had been ongoing problems with his aggression, and as the medical director made the recommendation for other client's and staff protection. When Z6 spoke with Z4, Z4 recommended another hospitalization for R3. Z6 said that when her concerns / recommendations were given to E1, E1 only said they would take the recommendation into consideration. Z6 said the facility did not seem concerned about R3's behavior. E1 said she was not aware the clients were afraid of R3 and was surprised that the clients did not like R3. Based on observation, interview and review of scheduling sheets, the facility failed to provide sufficient direct care staff to manage and supervise clients in accordance with their individual program plans for 15 of 15 clients at the facility. Findings include: Per observation of the facility on 1-29-02 at 9:00 AM, 15 clients were home from workshop for the day . Clients were in the living room or in their bedrooms. There were no activities occurring and clients were observed doing nothing. E2 was the only staff at the facility with 12 clients because E10, the other scheduled staff was at the dentist with 3 clients. Per the staffing schedule and interview with E1 and E12, there are 2 direct care staff scheduled from 7 AM - 10 AM. The 2 staff are responsible for assisting with medication, cooking, assisting with clients' personal and active treatment needs. Per interview and behavior reports, R3 has had multiple incidents of aggressive and intimidating behavior toward staff as well as clients. Per observation at the facility on 1-29-02, 2 clients require physical assistance for mobility. Review of the behavior management book revealed 11 of 15 clients have a behavior management plan for maladaptive behaviors: R1, R2, R3, R4, R6, R7, R8, R12, R13, R14, R15. Interview with E12 on 2-1-02 indicated she cooked on the week-ends and tried to monitor the clients while she was cooking during the time the other direct care staff assisted with medications and activities of daily living. The cook works from 10 AM - 6 PM daily. When the cook is not working after 6 PM, there are only 2 direct care staff to work with the clients. If an outing is scheduled for a few clients, 1 staff is left with the remaining clients. Verified by staffing schedule, there are a total of 6 staff for a 24 hour day. One of the 6 staff works as a cook. There are 2 staff scheduled from 7 AM - 10 AM Monday through Friday. One of the 2 staff must prepare breakfast. 2 staff are scheduled Monday through Friday from 6 PM - 10 PM. On week-ends, there are 2 direct care staff from 7 AM - 10 AM and 2 direct care staff scheduled from 6 PM - 10 PM. The cook comes on week-days and week-ends from 10 AM - 6 PM. Review of behavior and incident reports indicated many of the R3's and other clients' behaviors occurred in the evening when there were only 2 staff scheduled to work. The direct care staff who are scheduled are also responsible to take clients to medical and other appointments, leaving only 1 staff to work with the clients if the cook is not working. Per E1 interview, the staffing schedule is accurate. E1 said R3 is to be kept busy to prevent aggressive and maladaptive behaviors. She said in interview on 2-1-02 that the staff need to implement the behavior plan, but acknowledged that it would be difficult to keep R3 busy all the time with the available staff. Review of incident and behavior reports revealed many of the incidents with client's maladaptive behavior occurs in the evening and on the week-ends. Per interview and review of personal records and inservice training, the facility neglected to ensure that for employees who work with clients, training must focus on skills and competencies directed toward clients' behavioral needs for 15 of 15 clients at the facility who live in an environment with clients who demonstrate aggressive and maladaptive behaviors. Findings include: Per interview with E1 on 1-29-02 at the facility, R3's maladaptive behavior has not improved due to staff failing to intervene appropriately in R3's behavior. R3's behavior plan does not specify exactly how to intervene and prevent the behaviors from occurring. E2, E3, E5, E7, E10, E12 and Z5 all said in interview at the facility and the workshop on 1-29-02 and 2-1-02 that R3's behavior is unpredictable and explosive and cannot always be anticipated or redirected. E1 said there are certain interventions that should be consistently implemented, such as not telling R3 what to do, but phrasing requests in a non-commanding mode, and to redirect him into a physical activity, and reward him when his behavior is appropriate. Additionally, E1 said the staff are to remove R3 and not the other clients when R3 demonstrates aggressive or maladaptive behaviors. Per E3 and E10, other clients are removed from the area for protection when R3's behaviors are uncontrollable. When asked if training has been provided to teach staff to implement the interventions that would be successful to handle R3's behavior, E1 said no additional training had been provided. E10 said her only training had occurred when she took her hab tech training class for crisis prevention techniques several years ago. No additional training had been provided to deal with the 11 of 15 clients who have maladaptive behaviors at the facility. E1 said many times behavior that starts out as playful - type teasing and wrestling between peers ends up in physical / verbal aggression. E1 said some of the staff show fear of R3 and this is not acceptable. There is no evidence staff have had ongoing training in removing a violent and non-compliant client from a confrontational situation. The other staff interviewed all said R3 does not respond to redirection or positive reinforcement. E10 said she had never seen R3 respond the same way twice to redirection and he did not respond to consequences. E10 said the only instructions given were if there was trouble with one client, have the other staff intervene. E1 showed employee file for E3 that verified there had been no training directed toward clients' behavioral needs after E3 was told she handled R3's aggressive behavior on 1-17-02 in an inappropriate manner by locking several clients in the kitchen for protection from R3's aggression. Interview with E5 at the facility on 1-29-02 indicated many times R3's behaviors are not documented by all staff. Observed behaviors noted were masturbating in front of clients, turning lights off on clients, throwing objects at clients and staff and threatening and chasing staff and clients. E5 said that when R3 displays these behaviors, some staff say R3 is playing or think that what R3 is doing is funny. E10, as well as other direct care staff interviewed confirmed there had been no training in how to deal with R3's behaviors. There is no evidence there has been behavioral training for staff since R3 was admitted to the facility 6-01. R3 admitted that he knows he hits clients and staff, threatens to kill them, goes into client's rooms and has choked people. He said in interview at the facility on 1-29-02 that he scares clients because he thinks it is fun. Additionally he said he wants to be the center of attention and does not like to be ignored. No training has been provided to teach functional training techniques and effective data keeping procedures to monitor and prevent abuse and to ensure individual safety. Based on interview and record verification, the facility failed to revise a behavior program as necessary when 1 of 1 in the complaint investigation failed to make progress toward the identified objective (R3). Findings include: R3 is a 20 year old male with a diagnosis that includes mild mental retardation, ADHD and intermittent explosive disorder as noted on the resident roster. R3 has a formal training objective to display 0 incidents of maladaptive behavior for 6 consecutive recording periods. The target date for the objective is 8-2002. The operational definition of the behavior is defined as physical aggression, uncooperative behavior and teasing others. Physical aggression is defined as hitting others, pushing others, throwing items at others and similar behaviors that could result in injury to others. Uncooperative behavior is defined as refusing to perform a reasonable request by staff. Teasing others is defined as entering the personal space of others and touching them, making negative statements, talking to others loudly and similar behaviors. Review of documentation sheets revealed all behaviors are not documented. The specific behaviors documentation sheet does not list the specific behaviors noted in the operational definition. The behaviors to be documented on January 2002 data sheet includes aggressive behavior, cursing / threatening, non-compliant, and touching others inappropriately and talking inappropriately. Per observation on 1-29-02, R3 was teasing R2 when outside. No staff saw the incident to document it. E's 2, 3, 5, 7, 10 said in interview on 1-29-02 at the facility that R2 demonstrates intimidating, teasing, and threatening behaviors frequently. This was verified by R 1, R2, R4, R8, R10, and R12. As of 1-29-02, the only documentation of maladaptive behavior was noted on 1-17-02, although staff and clients said he demonstrates some of the behaviors frequently. R3 has not met the objective to have 0 incidents of maladaptive behavior for 6 months. R3's adaptive behavior is to state the rules of the facility and 1) Have opportunity to participate with peers in activities that involve social interaction. 2) Be provided with opportunity to participate with peers in community recreation and take turns while participating, thus improving personal-social skills while reducing maladaptive behavior. Per interview with E2, E3, E5, E7, E8, R3's behavior is explosive and at times occurs at times when he is involved in an activity. A progress note written by the psychiatrist on 1-4-02 stated he (R3) "was surprisingly aware of his behavior, and indicated he sleeps whenever he is bored and has nothing to do he likes...has difficulty complying with direct orders, no matter how well meant." The crisis intervention instructions in the behavior program states if the behaviors are displayed with such intensity or severity that R3 or others are at risk for injury, follow facility policies, including calling 911 to request immediate assistance. The behavior plan does not indicate what specific techniques should be used when R3 demonstrates the maladaptive behaviors. R3 was discharged from his last facility after he threatened a person at the home with a knife. R3 was hospitalized 7-16-01 and 11-04-01 for a psychiatric evaluation due to his aggressive behaviors. No change was made to his behavior plan. Interview per phone with E13 on 1-29-02 revealed R3 wanted a cigarette on 1-17-02 when he raged for 3 ½ hours and the staff should have just given him a cigarette (he is on a schedule for cigarettes). This was verified by E3 interview on 1-29-02. While clients were locked in the kitchen for protection on 1-17-02, staff called E1 and E13 for notification and advice regarding the situation. E1 and E13 said R3 should be given a cigarette and the staff should stay calm. Other than making a recommendation for technical assistance at the 1-23-02, the Treatment Review Committee ( TRC) / Human Rights Committee meeting, there is no evidence the facility made any recommendation or attempt to change the behavior program when it was noted that the current program was not effective. Verified by E1 interview at the facility on 2-1-02, the behavior program needed to be revised to address R3's specific needs.3 |