Complaint Investigation Report

Allegation: Staff did not provide adequate care and supervision

During investigation, LPA conducted interviews with reporting party (RP), staff (ADM) and reviewed client (C1) documents. ADM stated client (C1) has a 1:1 staff per shift assigned who monitors him at the facility 24/7. Review of C1’s progress notes dated 01/20/25 until 09/12/25 showed C1 engaged in serious injury behaviors (SIBs) mostly at the special needs school that he attends Monday to Friday from 7:30AM until 3:30PM. ADM stated C1 has increased serious injury behaviors (SIBs) since 09/12/25 and would hit his head without warning against a wall giving no time for the staff monitoring to prevent him from hitting his head against the wall. ADM stated that he has discussed C1’s serious injury behaviors with the Special Needs school Program Director, RCEB case manager, in-house Therapist and Psychiatrist . ADM stated they are working towards developing a care plan for C1 that would minimize his serious injury behaviors. ADM also stated he has scheduled a clinical team meeting with RCEB case manager to address C1’s SIBs and start using a padded cushion for 1:1 staff to use when monitoring C1. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide adequate care and supervision is unsubstantiated.

Exit interview conducted and a copy of this report provided.