01/15/2000
Among the 13-page report's allegations:
- A client who had not been seen for six days was found dead in her room on Jan. 7. The home's staff "had documented her absence as a leave of absence... without verifying that the client's family had picked her up."
- Incident reports alleging possible client abuse were not reported to the state Health Department. "When asked why this had not been done, the administrator said that she had delegated this to another person in the first instance and in the second instance she had not perceived... a problem."
- The center failed to ensure that all allegations of abuse were investigated and did not take precautions to ensure clients were not subject to further abuse by a staff member.
- The center failed to ensure client privacy during treatment and care of personal needs, including leaving partially nude patients exposed through open doors.
- The home failed to ensure that clients retain and use appropriate personal clothing and possessions, including clients whose pants fell down because they didn't fit. "Clients were unkempt in appearance. Male clients were unshaved and wore ill-fitting clothes. Clients also had dirty nails."
- The center failed to ensure all staff members working as qualified mental retardation professionals had adequate experience.
- The home failed to provide clients with a clean, comfortable mattress, as required by law. "Beds in client rooms throughout the facility were observed stained and dirty."
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