Res-care Washington INC (King County)

Client sustained head injury from fall on sidewalk but did not receive medical evaluation until next day at urgent care instead of emergency room per policy. Staff failed to implement required Head Injury Monitoring Tool with 15-minute checks for 2 hours, and multiple supervisory staff were unfamiliar with the facility's own head injury protocol. Facility conducted investigation and sent client for delayed medical care, but response revealed systemic gaps in staff training and policy implementation, with director and nurse delegator unaware of existing head injury protocols.

The facility failed to follow a client's prescribed bowel protocol on multiple occasions over a two-month period, with staff not administering prescribed constipation medication (polyethylene glycol) despite the client going 3-5 days without bowel movements on four separate instances. The facility demonstrated a good response by acknowledging the oversight, providing immediate staff retraining by the Delegating Nurse, and confirming existing supervision structures (weekly Area Supervisor reviews and monthly Health and Safety Case Manager reviews) were in place to prevent recurrence. A follow-up inspection three months later found all deficiencies corrected with no new violations identified, demonstrating sustained compliance improvements.

Caregivers restricted a client's access to their own food for over a year by storing it at another location, violating client rights without proper documentation or termination criteria. This represents a significant rights violation with potential for harm through unnecessary restriction and dependency. The facility had some behavioral plans and obtained consent, but failed to establish proper criteria, definitions, or monitoring protocols required for restrictive procedures, demonstrating inadequate safeguards for a vulnerable client's autonomy and wellbeing.