Complaint Investigation Report

Allegation: Client was injured due to lack of care & supervision from staff.

The details of the complaint alleged that a client in care was injured due to lack of care & supervision from staff.

During the records review, LPA Iniguez examined (C#1)'s Physicians Report for Community Care Facilities (LIC 602). It indicates that C#1 is capable of leaving the facility unassisted, walking without assistance, and does not require constant medical supervision. Additionally, LPA reviewed the Unusual Incident Report (LIC 624), which states that two facility staff members were present when C#1 climbed the neighbor's wall and sustained an injury. C#1 was never alone at the time of the incident. Furthermore, LPA review (C#1)’s care level, (C#1) was on a 30 minute check by facility staff.

During a facility tour, LPA observed two facility staff members, one chef, and one clinician. The facility currently has one client.

During an interview with the Executive Clinical Director (P#1), she stated that the client-to-staff ratio has changed from three staff members for every two clients to two staff members for every one client this is due to the current census. While (C#1) was living here, there were three clients, three facility staff, and clinicians and management available for any emergency. In addition, (P#1) stated that (C#1) got injured because they chased after their dog and climbed the neighbor’s wall, not because of a lack of supervision from facility staff. (C#1) was on a 30-minute supervision level at that time.

During interviews with facility staff (S#1-S#2), (2) out (2) stated that the facility ratio is two staff per client. Also, (2) out of (2) facility staff stated that (C#1) got injured not for lack of supervision from facility staff but because they were chasing after their dog that crossed into the neighbor’s property.