A Critical Examination of State Agency Investigations into ...

of time. Even the nurse confirmed there were no assurances his diet was being followedand monitored as prescribed.” Specifically, the surveyors found:• The Anderson School uses a planned ignore approach to behaviormanagement, but the approach has no time limits and prevents Jonathanfrom leaving his room. The surveyor reported that this practice, “taken inthe extreme in which it was used with [Jonathan Carey], constitutesseclusion, unauthorized time out or even neglect” (emphasis original).• The Anderson School does not seek or require “ written informed consentto implement behavioral approaches that involve untowardrisks/rights restrictions” (emphasis original).• Anderson School staff failed to follow Jonathan Carey’s prescribed diet.When questioned, even the nurse at the facility was unable to define acasein-free diet.• “Some nursing notes (10/9/04) revealed that, due to his maladaptivebehaviors, [Jonathan] was going for longer periods of time... withoutnourishment.”• Anderson School’s Director of Clinical Services told surveyors that if anindividual fails to act appropriately at meal time and for an extended timethereafter, there are no specified timeframes in which staff must offerindividuals any food.The surveyors stated that their greatest concern was “the failure – at all levels ofthe organization – to recognize when this behavioral intervention [planned ignoring]becomes abuse.”OMRDD Central Office officials discussed the problems at the Anderson Schoolduring an Early Alert meeting, a monthly meeting held at OMRDD Central Office toaddress problem programs, in November 2004. The minutes from the meeting reflectconcerns regarding the Anderson School: “[The] overall consensus seems to be aphilosophical problem from top down at [the Anderson School] relating to a poorunderstanding of: risk management, what determines abuse (physical/psychological),125