Maple Lodge

Violation established, special investigation : CCI Rule 400.4159 Youth restraint; pregnant youth; reduction, prevention;

The facility is found in noncompliance as evidenced by interviews with staff, youth and documents. Evidence supports the allegations of Youth A being inappropriately restrained by Security Staff 2 when Security Staff 2 placed his hand around the throat of Youth A along with Security Staff 2 utilizing a tripping method on Youth A, which is not an approved restraint technique. TECHNICAL ASSISTANCE: Technical assistance was offered regarding the facility ensuring staff pay attention to other staff and use a tap-out method if finding staff becoming dysregulated at any point. Staff should check in with their supervisor at the beginning of the shift to do a wellness check on their emotional wellbeing since engaging in a restraint is an extremely stressful event.

Repeat violation established, special investigation : CCI Rule 400.4158.1. .1.a.iv Intervention standards and

The facility is found in noncompliance as evidenced by interviews with staff and documentation reviewed, evidence supports Security Staff 2 engaged in the use of derogatory language towards Youth A during the restraint.

Repeat violation established, special investigation : CCI Rule 400.4109 Program Statement

Facility was found in non-compliance of Staff 1 not following the facility’s supervision policy. Within the interviews with Staff 1, Staff 2, and Youth A it was found that Staff 1 allowed Youth A to hold the home phone and make her own phone calls unsupervised which is against Youth A’s safety plan. Staff 1 admitted to not reviewing Youth A’s precaution orders prior to his shift which is noted in the supervision policy.

Repeat violation established, special investigation : CCI Rule 400.4158 Intervention Standards and prohibitions

The facility is found in violation as per interviews conducted, Security called Youth A, a profane name and used profanity when speaking to Youth A. TECHNICAL ASSISTANCE The facility should ensure all non-Maple Lodge specific staff who report for incidents and/or have contact with the facility’s youth have an overview of the facility’s programming prior to assisting with the facility’s youth.

Violation established, special investigation : CCI Rule 400.4109 Program Statement

The facility is found in violation as per the interview conducted and documentation reviewed, Security did not complete Trauma Informed Environment Training as required by the facility’s Behavior Management Policy and did not complete a QBS Safety refresher annually on or before the previous date taken as required by the facility’s QBS Training Requirements Policy. In addition, Security’s employee file did not show corrective action was taken as a result of his expired certification. TECHNICAL ASSISTANCE The facility should ensure all non-Maple Lodge specific staff who report to incidents and/or have contact with the facility’s youth complete Trauma Informed Environment Training as required by the Facility’s Behavior Management Policy as well as any other trainings listed in various other Maple Lodge policies.

Violation established, special investigation : CCI Rule 400.4158 Intervention standards and prohibitions

The facility is found in non-compliance as per interviews, Staff 1 did yell at Youth A and other youth at the facility when the milieu was escalated.

Violation established, special investigation : CCI Rule 400.4126 Sufficiency of staff

The facility is found in non-compliance as per interviews conducted and documentation reviewed, Staff 1 did not follow supervision requirements or youth safety plans, and as a result, two youth were left unsupervised and had sex on a community outing. TECHNICAL ASSISTANCE: It is recommended the facility update their supervision and/or managing community outings policy for community outings to note only one youth should be in the changing room or restroom at a time while the rest of the youth stay with an assigned staff. The facility was provided an example of another CCI’s policy on 12/27/24 for reference. It is recommended the facility update their managing community outings policy to include supervision requirements/expectations of staff while on the community outing.

Violation established, special investigation : RFCAN contract Unplanned discharge of a youth

Evidence provided through interviews and written documentation do support the allegations of the facility not following through with their contract requirement to keep Youth A in care until further placement was found. There was no evidence found to support that a return to the facility was against medical advice and the facility still had eight days left until the 30-day notice was up. Although, there is evidence to support that this placement was not appropriate for the issues Youth A was presenting, the facility was still under obligation to continue placement at the time Youth A was discharged from the hospital on August 5, 2021.

Violation established, special investigation : R 400.4126 Sufficiency of staff

Residents were able to engage in sexual contact with one another while they were congregated near a resident’s doorway and while outside during which time staff were not providing continual supervision of the residents.