Complaint Investigation Report

the injury could have occurred from direct force to the sternum or a flexing (bending) injury. The Department interviewed fourteen (14) staff. Four (4) of the staff were present at the time of the incident. Staff 3 (S3) and Staff 4 (S4) were involved in the restraint placed on C1 twice in the same day. During interview with Staff 5 (S5) it was stated that on 10/20/2022, S5 observed C1’s wrist being bent all the way down (demonstrated) and S3 took C1’s head and shoved it down between C1’s legs (demonstrated). Staff 6 (S6) was also present during the incident on 10/20/2022 and stated C1 was upset, staff started to escort C1 to his room when C1 tried to inflict self injurious pain. S6 further stated later the same C1 tried to grab S5’s ponytail, so staff tried to escort C1 back to his room. S6 stated while staff was escorting C1 he went back to get a sweater and when he returned to the hallway S3 and S4 had C2 had to restrain C1 a second time on 10/20/2022. S6 recalled during the interview that a few days after the incident C1 complained about chest pain and was taken to the hospital. LPA interviewed C1. During the interview with C1 it was stated that S3 and S4 beat him up and that it happens all the time. Based on the investigation the above allegations are substantiated.

On the allegation Staff are mistreating a client while in care. LPA reviewed the detailed supportive information received from the RP on 11/15/2022. The RP stated an email was received from S5 that stated there were two staff members and S3 and S4 were named, that were mistreating and handling the clients roughly. S5 stated there was a previous incident (unknown date) it was observed where S3 and Staff 4 (S4) had C1’s arms pulled back, put pressure on C1’s back, and put C1’s head between his legs. S5 stated C1 was grasping for air. On 1/12/2023, LPA received and reviewed the investigation that was completed in-house by the facility, which stated based on witnesses statements the facility determined that staff S3