6400.186 | Individual #1's Individual Service Plan (ISP) is not being implemented. Individual #1's ISP states that a seizure protocol is located at Individual #1's home for staff to follow. It further states that Individual #1 benefits from line-of-sight supervision if the individual were to go outside of the home to visit the yard or take out the trash. It also states Individual #1 showers independently, however due to a seizure disorder; staff perform visual checks to ensure safety and Individual #1 can spend time alone in the individual's bedroom and the bathroom with staff completing visual checks due to seizure disorder. On August 21, 2022, Individual #1 was observed to have bruises of various sizes and shapes on the individual's left arm, under the individual's breast, right arm, and left leg. The bruises were documented and reported by staff on August 21, 2022. It is unclear how these bruises were obtained as Individual #1 stated during two separate interviews "I fell taking out the garbage." There were not any witnesses to Individual #1 falling while taking out the garbage. Staff who were interviewed reported that Individual #1 had not taken out the garbage leading up to the time that the bruises were observed. Through interviews with Individual #1 and staff assigned to work in Individual #1's home, it was unable to be ascertained how the individual received the bruises. Information obtained through interviews during the investigation regarding the unknown bruises, showed that Individual #1's ISP is not being implemented as all staff are not completing visual checks of Individual #1 while the individual is in the bathroom and showering. Individual #1 was observed through the bathroom door being open on 8/20/22 after showering, to be unclothed and walking around appearing confused. Individual #1 had been in the bathroom to complete a shower and visual checks were not completed until it was observed that the individual had opened the door and staff observed the individual to be naked. The individual was instructed to close the door and only after being nonresponsive did the staff proceed to go to check on the individual. Individual #1 did not have any injuries upon staff checking on the individual. It is unknown if the individual had a seizure, or was not hearing or dismissing staff speaking to the individual. | The home shall implement the individual plan, including revisions. | Individual #1¿s seizure protocol was updated to include seizure symptoms specific to the individual. The seizure protocol was added to the ISP for individual #1. All staff in the home were retrained on the seizure protocol and visual checks. |
10/10/2022
| Implemented |