Res-Care Washington INC (king County)

After Client 1 tripped, fell on a sidewalk, and struck their forehead, staff failed to follow the provider's head-injury emergency procedures. Staff did not initiate the required Head Injury Monitoring Tool, resulting in inaccurate monitoring, delayed care, and risk of complications from a possible head injury.

Provider failed to follow head injury policy after a client suffered a fall and head injury; staff did not initiate the required Head Injury Monitoring Tool, resulting in delayed care.

The provider failed to effectively implement and train staff on policies addressing client rights, including protection from harm and the right to make complaints or suggestions without interference.

Staff forcibly restrained Client 1 and cut the client's pubic hair despite repeated physical resistance, then photographed the client's genital area using a personal cell phone. The incident was not reported to the client's case manager or the department within the required one-hour timeframe; it was reported 14 days after the provider was notified.

The provider failed to immediately report the suspected physical assault and restraint of Client 1 to law enforcement.

The provider failed to implement policies and procedures to protect clients after allegations of abuse, including allowing involved staff to continue working with clients.

The provider failed to protect Client 1 and other clients from further risk by allowing staff members involved in the incident to continue working with clients after the provider was notified.

The provider failed to immediately report the suspected sexual assault of Client 1 to law enforcement. No provider report was identified, and law enforcement was not contacted at the time of the incident.

The provider failed to protect Client 1 from unnecessary physical restraint and abuse. Staff restrained Client 1 and shaved the client's pubic hair despite resistance and without consent, and the client's genital area was photographed.

The provider failed to immediately report the suspected sexual and physical assault involving Client 1 to the department.

The provider failed to ensure staff followed policies and procedures for reporting suspected abuse, neglect, financial exploitation, or abandonment.

The provider failed to immediately report suspected abuse to the department. The provider learned of the incident on 2024-08-14 but reported it on 2024-08-28, approximately 14 days later.

The provider restricted the client's access to food purchased by the client by storing it in another location. The restriction was implemented without adequate documentation describing when and how it would be used, criteria for termination, or a plan to document its use and effect.

Provider failed to ensure client had unrestricted access to purchased food. Staff were hiding client's food in an office or a neighbor's apartment without proper documentation of a formal restrictive procedure, criteria for termination, or a plan to document the effect of the restriction.

Provider failed to train staff and provide oversight on water temperature protocols, resulting in Client 1 sustaining a second-degree burn.