A Critical Examination of State Agency Investigations into ...

Jonathan’s “demeanor has changed significantly,” a factor that could have represented thepossible manifestation of some emotional injury.Incomplete or inaccurate findings regarding provision of mealsThe Inspector General’s Office found that CQC overstated its determination thatthe Anderson School provided substitute food items to Jonathan when he did not eat hisregular meal. This finding was not supported by the evidence.According to CQC’s Facility Investigation Summary Report, which wastransmitted to the State Central Register, “when Jonathan did not get his regular meal, hewas offered alternate food items in his room.” Similarly, CQC’s April 28, 2005 letter toMichael and Lisa Carey concluded, “In an attempt to manage Jonathan’s periodic refusalto put on clothes to come to the table and eat, staff did withhold his regular meal andoffer a basic nutritional substitute as part of his behavior plan.” These letters and reportssuggest th at CQC was able to verify that substitutes were offered each and every timewhen Jonathan was not afforded his regular meal.However, the evidence obtained by the Inspector General from the AndersonSchool and from CQC does not support this conclusion. Although the Anderson Schoolbegan withholding meals from Jonathan on September 27, 2004, his behavior planincluded no instructions for staff on what substitute foods, if any, to offer Jonathan if hedid not eat his regular meal between September 27 and October 9, 2004. Furthermore,staff did not consistently document his food intake, and the nurse did not identify specificsubstitute food items for Jonathan until October 9, 2004, almost two full weeks later.168