Complaint Investigation Report

The investigation reveals the following: Regarding “Resident sustained injuries due to staff neglect”. It is alleged that a client has bruises on their back and arm. The Program Manager and Administrator stated C1 exhibited bruises due to being hospitalized. On 5/10/2024 C1 collapsed at the facility and was grasping for air. The facility contacted emergency personnel where C1 remained hospitalized from 5/10/2024 – 5/15/2024. During a hospital visit on 5/11/2024 staff stated they witness a bruise on C1’s back when C1 was moving around. 4 out of 4 staff confirmed C1 had bruising on their hands due to the IV. Staff stated that C1 pulled out the IV’s and the medical staff also had a hard time finding a vein. 3 out of 3 witnesses confirmed they did not observe bruises on the clients in relation to staff neglect. W1 stated C1 has never showed signs of neglect or being abused by the facility. W2 confirmed C1 has been hospitalized a total of three (3) times within the last month. LPA reviewed client files and incident reports and confirmed C1’s collapsed which led to hospitalization. LPA also received photos of C1 during hospitalization and observed the bruises caused by the IV.

Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid,

there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the

Exit interview conducted with the Administrator Ashilee Jackson and a copy of this record provided.