Complaint Investigation Report

LPA interviewed 3 individuals from two other outside agencies. According to their interviews, they do not have current concerns regarding the facility. One agency had an internal investigation, which results are unknown at this time. However, the individual could not say whether the allegation is true or false due to R1's past behaviors. The other agency provided LPA documentation relevant to the investigation and stated their observations of staff interactions have been positive.

LPA Valerio interviewed facility staff. Interviews with staff 4 and staff 5 were attempted and unsuccessful. According to staff 1 (S1), no incidents have occurred that resulted in a resident handled in a rough manner by staff. S1 is at the home frequently and has never observed any staff handling residents in a rough manner. According to staff 3 (S3), S3 stated, "if anything, it is us protecting ourselves from getting hit or protecting other residents from being hit or rough handled. We all do the best we can, and document everything we can." According to an interview with S2, S2 believes if anyone had a concern with the resident being in the home, the resident should have been moved out of the facility. S2 stated S2 has never handled any residents in a rough manner. S2 stated there was an incident involving S2 and R1. S2 was at a desk filling out paperwork. R1 went up to S2 and tried to grabbed the papers. S2 told R1 that R1 could not grab the papers. R1 proceeded to attempt to grab the papers while charging S2 with a pencil in R1's hand. S2 stated, "I grabbed [their] wrist because I did not know [their] intentions." According to interviews, no other staff or residents witnessed the incident.

According to records review from an outside agency and the facility, a daily note was written on 05/17/22. The daily note reads, "05/17/2022 - Tuesday, Very impulsive and unsafe with action. "[R1] grabbed papers from my desk, I removed [their] hand from my desk and [they] lunged at the desk and me with a sharp pencil in [R1] right hand. I stopped [R1] by grabbing […] wrists and told [R1] to stop. I was worried [they] could hurt [themselves] with [the] pencil." According to record documentation, records show that R1 has behaviors that may be sudden or outburst that require staff to attempt to redirect or de-escalate the resident. If staff are faced with such behaviors, they have been trained to act in a specific manner. The document states if the resident "…engages in less severe problem behaviors (verbal aggression, emotional outbursts, and noncompliance) staff will: Minimize attention (e.g. divert eye contact, use short direct statements only when needed, do not provide physical touch unless necessary to keep staff and consumers safe) for the specific problem behavior." Based on record review, staff used physical touch to ensure the safety of staff and resident.