A Critical Examination of State Agency Investigations into ...

notified and she consented to the medication increase the next day, according to clinicalcontact records.On October 12, 2004, Jonathan’s logbook and behavioral reports showed thatJonathan was “relatively cheerful” but was without his pants while in his room. Jonathanrefused all prompts to get dressed for snacks, dinner, or walks. Staff noted new bruiseson Jonathan’s back and under his chin. The nurse and pediatrician examined him. Thepediatrician wrote that Jonathan had been in behavioral crisis, with some improvementafter Michael Carey’s visit two days earlier. He was eating and drinking better,according to progress notes. The pediatrician also documented that Jonathan hadmultiple bruises due to self-injurious behavior and recommended that Jonathan beweighed weekly and that Jonathan’s intake and output be recorded.On October 13, 2004, Jonathan refused to use the toilet or leave his bedroomalmost the entire day, even needing to be carried out for a fire drill in the morning hours,according to his personal communication logbook and the Birch Residence log, which ismaintained in the residence and is used to document daily and significant events there.In response, a Treatment Team Problem Solving Meeting was held that day with12 Anderson School administrators and clinical staff. It was noted that Jonathan hadmany marks on his body from “escorting him immediately after flopping, attempting torun out of the house and throwing himself into the railings on the front porch at theresidence.”Concerns were raised about Jonathan’s intense behaviors and discussions ensuedregarding appropriate services, including questioning whether the Anderson School was72