Complaint Investigation Report

Regarding the allegation that, “Resident sustained unexplained injuries while in care”, it was alleged that school staff noticed that C1 had severe burns his back which seemed like rug burns.

To investigate this allegation LPA spoke with the staff and client. Interviewed S1 stated that they noticed rug burns on C1 neck on 12/01/23 when they pick up C1 from the school. C1 is attending to Le Roy Haynes school. S4 who was with S1 at that day also confirm that they noticed the burn mark on the C1's neck. Before they didn't notice any marks on C1's body / neck. Interviewed administrator and house manager stated that facility staff are doing body check every day and when clients are outing. LPA obtained copies of Body assessment sheet / body chart for C1 dated 11/19/23, 11/30/23, 12/1/23 to 12/4/24.

Administrator stated that they didn't observe any rug burns / marks on C1's body before 12/1/23. On 12/1/23 at 11:00 am Administrator received the phone call from school staff who told the administrator that they noticed rug burns on C1's neck. On the administrator question that how is C1 is feeling, the school staff said that C1 is ok and there is no sign of discomfort or pain. At 1:00 pm school staff called the administrator again and ask for transportation for C1, because of C1's behavior. C1 refused to go in the school bus. S1 and S4 transported C1 back to facility. After C1 came back the administrator applied first aid and C1 was monitored throughout the day. Interviewed S5 stated that they noticed rug burns on C1's neck after C1 returned back from the school on 12/01/23. Interviewed C2 stated that they scared of C1 and doesn't want to talk about C1. C2 stated that C1 very aggressive and bite everyone.

A review of facility records conducted revealed that although the staff conducted a body check based on Facility policy, the information was not documented daily in the facility records / Body assessment sheet / body chart. All the information is in home base, but not in the facility chart. LPA advise the administrator to have all the information on the facility chart.

All interviewed staff reported they observed C1 had unexplained rug burns on C1 neck but unable to find out what had happened.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.