RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD WELFARE LICENSING LANSING NICK LYON DIRECTOR June 7, 2016 Troy Mitchell Wolverine Human Services 15100 Mack Ave. Grosse Pte. Park, MI 48231 RE: License #: Investigation #: CI730201515 2016C0634028 Wolverine Secure Treatment Center Dear Mr. Mitchell: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each rule will be achieved. Who is directly responsible for implementing the corrective action for each violation. Specific time frames for each violation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. The signature of the responsible party and a date. If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action. 611 W. OTTAWA P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/lara 517-335-1980
Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact Greg Corrigan, Area Manager, at 269.337.5289. Please note that violations of any licensing rules are also violations of the MSA and your contract. Sincerely, Bill White, Licensing Consultant MDHHS\Division of Child Welfare Licensing Suite 11 701 S. Elmwood Traverse City, MI 49684 (231) 342-5037 enclosure 611 W. OTTAWA P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/lara 517-335-1980
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: CI730201515 2016C0634028 Complaint Receipt Date: 05/24/2016 Investigation Initiation Date: 05/24/2016 Report Due Date: 07/23/2016 Licensee Name: Licensee Address: Wolverine Human Services 15100 Mack Ave. Grosse Pte. Park, MI 48231 Licensee Telephone #: (313) 824-4400 Administrator: Licensee Designee: Name of Facility: Facility Address: Judith Fischer-Wollack, Designee Judith Fischer-Wollack, Designee Wolverine Secure Treatment Center 2424 N Outer Drive Saginaw, MI 48601 Facility Telephone #: (989) 776-0400 Original Issuance Date: 09/01/1997 License Status: REGULAR Effective Date: 09/30/2015 Expiration Date: 09/29/2017 Capacity: 100 Program Type: CHILD CARING INSTITUTION, PRIVATE 1
II. ALLEGATION(S) Inappropriate use of restraint on resident Violation Established? Yes III. METHODOLOGY 05/24/2016 Special Investigation Intake 2016C0634028 05/24/2016 Special Investigation Initiated - Letter email 05/26/2016 Inspection Completed On-site 05/26/2016 Inspection Completed-BCAL Sub. Compliance 05/26/2016 Exit Conference ALLEGATION: Inappropriate use of restraint on resident. INVESTIGATION: Resident s B and C were interviewed using forensic protocol. Resident B stated that he and another resident were talking about Resident B using the shower before the other Resident A cleaned it. Resident B did not like the resident s response and started walking toward him. Resident B stated that staff, Mr. Garcia got in between he and Resident A and moved him away. Resident B stated that while he and Mr. Garcia were moving away, Resident A picked up a chair and hit them with it. Resident B stated he was hit on the right side of his head. Resident B stated that another staff (Gregory Haney) moved Resident A toward his room and he, (Resident B) started running toward him. Resident B stated staff, Mr. Garcia grabbed him from behind, putting his arms around his waist, and pulled him backward, turning him to the side, causing him and Mr. Garcia to fall to the floor. Resident B stated he hit the floor with the right side of his head and his body. Resident B stated he told Mr. Garcia he was feeling dizzy and it was noticed that he was bleeding from his head. Resident B stated that a nurse came to the unit and he was taken to the hospital. Resident B stated he did receive stitches above his right eye. Resident B s head was observed and I did see stitches above Resident B s right eye in the eyebrow. 2
Resident C stated Residents A & B were arguing. Resident C stated Resident B needed to shower. Resident C stated the residents came together and staff Garcia pushed Resident A away. Resident C stated Resident A picked up a chair and ran at Mr. Garcia and Resident B, swinging at them and hitting both of them on the head. Resident C stated Resident B then ran after Resident A and Mr. Garcia followed him, grabbing him from behind. Resident C stated that as Mr. Garcia was pulling Resident B, he lost his footing and he and Resident B hit the floor hard. Resident C stated that Resident B did not move and when Mr. Garcia told him to stand up, Resident B said he couldn t, he felt pain and was dizzy. Video footage of the incident was observed. The footage shows Resident B confronting Resident A. At the time of the initial exchange, Mr. Garcia was sitting by a room. Mr. Garcia gets up and pushes Resident A away from Resident B and begins to move away with Resident B. As Mr. Garcia and Resident B are moving away, Resident A picks up a chair, raises it above his head and moves toward them. Staff Gregory Haney moves toward them, attempting to block the chair. Resident A swings the chair down and one leg of the chair hits Mr. Garcia in the back of the head, while another leg hits Resident B along the right side of his head. Video footage shows Mr. Haney moving Resident A to his room and Resident B turns and begins running toward them. Staff Garcia runs toward Resident B, grabbing him around the chest area from behind and pulls him backward. At this time Resident B turns to his right and both Mr. Garcia and Resident B fall to the floor. After falling to the floor, Mr. Garcia gets up and is seen talking to Resident B, who remains laying on the floor. Eventually Resident B gets up and a staff takes a picture of his head. Mr. Ricardo Garcia was interviewed. Mr. Garcia confirmed the events of the incident. Mr. Garcia stated that he did not get up sooner and confront the resident s due to being told to watch who was on suicide watch. Mr. Garcia stated that when he came on shift he was told he needed to watch another resident who was on suicide watch and that another staff would be sent down to cover for him and this did not happen. Mr. Garcia acknowledged he had received training in restraint management while at Wolverine High Secure. Mr. Garcia s personnel file was reviewed. Mr. Garcia has been an eleven year employee at Wolverine Human Services. Mr. Garcia s file showed he had received training in the use of restraint on 2/2016 and 4/2016. Mr. Garcia has not received any discipline for improper use of restraint during his eleven years at Wolverine. 3
Mr. Mitchell, director, stated Mr. Garcia did not use the proper restraint technique taught by Wolverine High Secure. Technical assistance was offered, advising that each unit have a minimum of three direct care staff on duty during awake time in order to insure that a sufficient number of direct care and other staff are on duty to perform the prescribed functions required by these administrative rules and in the agency s program statement and to provide for the continual needs, protection, and supervision of residents. APPLICABLE RULE R 400.4112 Staff qualifications. (1) A person with ongoing duties shall have both of the following: (a) Ability to perform duties of the position assigned. (b) Experience to perform the duties of the position assigned. ANALYSIS: Mr. Garcia is an eleven year employee of Wolverine Human Services. Mr. Garcia has received training in the use of restraint, the earliest being 2/2016 and 4/2016. Mr. Garcia acknowledges that he performed a one person restraint on Resident B while he was moving toward Resident A. Mr. Garcia acknowledged that he and Mr. Haney were the only staff in the unit at the time and there was no time to call for additional staff. Mr. Garcia stated that he did not use the proper restraint technique on Resident B. CONCLUSION: VIOLATION ESTABLISHED APPLICABLE RULE R 400.4126 R 400.4126 Sufficiency of staff. Rule 126. The licensee shall have a sufficient number of administrative, supervisory, social service, direct care, and other staff on duty to perform the prescribed functions required by these administrative rules and in the agency s program statement and to provide for the continual needs, protection, and supervision of residents. 4
ANALYSIS: Mr. Garcia stated that he would have attempted to intervene sooner between Resident A & B, however he was on suicide watch with another resident, and did not feel he could leave his station. This meant that there was only one other staff, Mr. Gregory Haney, available to deal with any potential issues that may arise. Wolverine High Secure did not have a sufficient number of direct care and other staff on duty to perform the prescribed functions required by these administrative rules and in the agency s program statement and to provide for the continual needs, protection, and supervision of residents. CONCLUSION: VIOLATION ESTABLISHED IV. RECOMMENDATION Upon approval of an acceptable corrective action plan, I recommend no change to this Child Caring Institution license Private. June 6, 2016 Bill White Date Licensing Consultant Approved By: June 7, 2016 Gregory V. Corrigan Date Area Manager 5