Complaint Investigation Report

Allegation: Staff did not prevent client from physically abusing another client in care resulting in injury

During investigation, LPA conducted interviews with reporting party (RP), facility staff (ADM, S1) and reviewed client’s (C1) documents. ADM stated that on 04/07/26 at 4AM, C1 unexpectedly displayed aggressive behavior towards his roommate (C2). Review of incident reports submitted on 04/07/26 showed C1 bit C2 on the head at 4AM. Staff immediately addressed the incident, treated C2 with first aid and redirected both clients. Staff stated they increased monitoring of C1 to prevent him from biting another client.

ADM stated he notified responsible parties including Adult Day Program staff to closely monitor C1 for behavioral expressions. ADM also stated he has scheduled C1 to see his primary care physician (PCP) and behaviorist to address his change in condition. C1 was also relocated to another bedroom with another roommate. ADM stated night staff checks on C1 every hour to ensure he does not display any aggressive behaviors towards other clients. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not prevent client from physically abusing another client in care resulting in injury was found to be unsubstantiated.

Exit Interview conducted and a copy of this report provided.