Professional Documents
Culture Documents
Summary of Investigation
PRIVATE ICF/IID PROVIDER
Case Number: E1410020 Waiver: DIDD ICF/IID DIDD Investigator: Robin Bailey
Agency Responsible: Orange Grove Center
Date: 10/24/2014
I. Initial Allegation(s):
It was reported that at an unknown time on 10/12/14, the Nurse, T.A. was
observed giving the person supported his medications with a large amount of
pudding then pouring Ensure in his mouth. The person supported was reportedly
not able to swallow all of this. She was stopped when she started pouring Ensure
in his mouth. It was also reported that T.A. held the person supporteds head and
said to 'Straighten up and quit acting out'. It was additionally reported that staff
D.J. was later observed transferring the person supported (who requires a 2
person transfer) from his wheelchair to his bed by himself. This resulted in the
person supported going 'head first' onto his bed. The person supported was not
injured as a result. Based on the information provided, DIDD will investigate the
allegations of neglect and abuse.
II. Conclusion(s):
There is not a preponderance of the evidence to support that staff member T.A.
did not emotionally abuse the person supported by improperly administering his
medications on 10/12/14 at bedtime. The allegation of emotional abuse is not
substantiated.
1
b. What procedures, if any, have been developed and implemented for
protecting people from further abuse, neglect and/or exploitation; and
c. If the incident was not reported to DIDD in a timely manner (as noted in
the final investigation report, section IV. B.), what has been done to
address late reporting.
2
C. It is recommended that the Administrator email the corrective action plan to
DIDDINVPOC.East@tn.gov within fourteen (14) calendar days from the
release of this report. The release date is the day the Office of Investigations
forwarded the report to the Provider via email.
V. Incidental Findings:
Per the DIDD Provider Manual, Chapter 7, 7.4.8.b, for Community Providers and Private
ICF/IID or the Protection from Harm ICFs/IID Policy 100.1.1., VI.K.8 for DIDD ICF/IID
Facilities, the summary of this investigation should be discussed with the person(s)
supported within fifteen (15) business days of the receipt of the report. If a legal
representative has been appointed, that person should be invited to participate in this
discussion. The space below has been provided for your convenience as a means by
which for you to document the fulfillment of this requirement.
Printed Name
Witness:
Printed Name