Complaint Investigation Report

was assisting C1 with their personal needs. C1 became upset, grabbed the one-on-one care provider’s hands and a facility staff member intervened. The facility staff member allegedly pushed C1 to the wall, led C1 to the living room couch, and held down C1’s hands on the couch.

The reporting party provided the name of the staff member. LPA Spaeth interviewed the Administrator and Facility Manager on 4/04/23 at 11:00 am and interviewed four staff members (S1, S2, S3, S4) out of the eleven (11) staff members on 6/12/2024 via phone call who unanimously stated there was no caregiver by that name.

S1 - S4 stated that they have never physically assaulted a client, have never witnessed another staff member assault a client, and the clients have never stated a staff member has assaulted them. S1 – S4 all stated when a client becomes aggressive, they verbally try to redirect the client in a calm voice but never use force. The four staff members also stated they have never held down a client when the client exhibits disruptive behaviors. S1 -S4 all stated they have learned what verbal strategies work for each client and will positively reinforce those verbal strategies when a client is aggressive. S1 – S4 have confirmed they have received the CPI training and, also stated they immediately report any aggressive behaviors to the Administrator and to the Facility Manager.

The Administrator and Facility Manager confirmed all staff members have received the required training, have been instructed to report aggressive behaviors to the Administrator and the Facility Manager. The Administrator and the Facility Manager stated staff have not stated they witnessed another staff member holding down a client. The facility clients have never reported to them that a staff member has assaulted them.

LPA Spaeth attempted to interview C1 but C1 refused. During LPA Spaeth’s 4/04/2023 visit, three (3) out of the four (4) residents were participating in community activities and were unavailable for an interview.

LPA received copies of client’s records which reveal C1 does have disruptive behaviors. LPA reviewed two incident reports which state C1 was physically aggressive toward facility staff. At 11:45 am, LPA Spaeth reviewed the CPI Foundation Participants Guide and observed Unit 8 Physical Interventions-Disengagement Skills section provides specific training on how to divert specific behaviors without physically holding down the client.

Based upon staff interviews and review of the client’s records, the allegation, resident was physically assaulted by staff is unsubstantiated . Exit interview conducted and a copy of the signed report was given.