Complaint Investigation Report

Allegations: Staff hit and Staff Pushed Client

It is alleged that on December 10 at approximately 2:30 p.m., a Direct Support Professional hit client and pushed a client during a behavioral episode. It is further alleged that the same staff member yelled at clients and used derogatory language toward them. It is alleged that this behavior is ongoing and not an isolated incident, and that other clients may have been treated in a similar manner. It is further alleged that staff have used objects, including a broomstick, to intimidate clients and cause them to remain quiet or comply with staff direction.

During client interviews, clients C1–C4 were identified as non-verbal. LPA attempted to interview client C1 regarding the above allegations; however, the client was unable to respond due to difficulty understanding. . During observations, clients were observed to appear comfortable in their surroundings. During record review LPA obtained current certified CPI training . A dditionally , LPA was informed that clients have not been placed in CPI holds, as the facility utilizes positive behavior support plans in lieu of physical interventions.

During the investigation, LPA spoke with witness #1 (W1) who previously conducted a wellness check at the facility. The witness reported no concerns related to client care, staff interactions, or client safety at the time of the wellness check.

During staff interviews, staff members S1–S7 provided consistent responses and reported they have not observed any staff hitting and pushing. Staff stated that when clients become agitated or upset, staff attempt to calm them by asking what is wrong and identifying the client’s needs. Staff reported that behavioral interventions are de-escalation based and do not involve the use of force, threats, or aggressive actions .