A Critical Examination of State Agency Investigations into ...

On the morning of October 9, the Director of Clinical Services arrived to findJonathan in his bedroom. According to medical records and interviews, Jonathan wasnaked and covered with bruises. The Residence Manager and a nurse were already in thebedroom assessing Jonathan’s condition. The Director of Clinical Services wrote in herstatement that “Planned Ignoring procedures outlined in his [Behavior Support Plan]were not being followed,” apparently because staff were present in Jonathan’s room withhim.Records and interviews with staff at the Anderson School revealed that Jonathansustained bruising throughout this crisis period. The bruising that was observed onOctober 9 was documented in an Anderson School Student Injury/Illness Report, asdisplayed below. The nurse who filled out the form also noted that Jonathan’s lips werebecoming dry and instructed staff to offer him juice and ice pops.Staff at the Anderson School decided that something had to be done to addressJonathan’s behaviors and to ensure that he received nourishment. The Executive Directorheld a meeting that day with the Director of Clinical Services, the Residence Manager,and a registered nurse.A medical note, written by a nurse on October 9, 2004, noted, “It is becomingmore frequent that he will not [get dressed to eat] and longer periods of time areoccurring without nourishment.” This nurse reported to the Inspector General’s Office:“When I saw him on Saturday [October 9] and found out he had not eaten in a day; thatseemed to be beyond a behavior plan.” She contacted the Director of Clinical Servicesand told her that the behavior plan was not working and needed to be changed.65