Complaint Investigation Report

On 3/20/2023 LPA conducted a follow-up interview with Ingrid Wilson-Executive Director.

On 3/28/2023 and 3/29/2023, LPA conducted interview with (W1) who is with C1’s placement agency and 3 Staff (S7-S9).

The investigation revealed the following:

Regarding the allegation: Multiple staff hit resident in care.

On 9/27/2022, 3/28/2023 and 3/29/2023, LPA conducted interview Client (C1), Ingrid Wilson-Executive Director/Licensee, Staff (S1-S9) and (W1) who is with C1’s placement agency. LPA obtained the following documents for review: Unusual incident Report (date), staff/clients roster, Residents (C1’s) Physicians Reports, C1’s IPP, C1’s Behavior Notes, Client Emergency Contacts, and staff members training records.

The complainant alleges that C1 was taken to the bathroom and struck multiple times by staff members (S7-S9) on 9/14/2022. On 9/27/2022, LPA conducted an interview with Client (C1). During the interview, LPA observed a small red mark, approximately the size if a quarter, located on the left side of C1’s head. C1 stated,, “I like to lay my head on the table” when asked about the red mark. C1 stated , they are treated “good” by staff when asked about relationships with staff. On 9/27/2022, LPA conducted an interview with Ingrid Wilson-Executive Director, who stated C1 reported staff (S7-S9) struck C1 in the restroom on 9/14/2022, and this is why C1 has a small red mark. Ingrid Wilson- Executive Director also stated the (3) staff members are no longer working at the facility. LPA conducted interviews with Staff (S1-S6), (6) staff stated they have not witnessed the physical abuse of C1 or other clients while working at the facility. During interviews with staff, (3) of (6) staff stated they observed a red mark on C1’s head but it did not appear to be a bruise. Staff were unable to determine the cause of the mark on C1’s head. On 3/28/2023, LPA interviewed (W1) with C1’s placement agency. W1 stated, the placement was made aware of the abuse report and investigated the matter. Based on information gathered, W1 determined the origin of C1’s bruise may have been due to a fall. On 3/29/2023, LPA conducted telephone interviews with the (S7-S9 ), the staff who allegedly struck C1. Staff S7, S8, and S9 stated they were unaware of C1 having bruising. S7 and S8 denied any inappropriate physical contact other than providing support to C1 while in the shower and physically supporting C1 to the bedroom after as C1 is provided an enhanced ratio of 2:1 due to a history of falls. LPA found S9 was not present during C1’s shower on 9/14/2022 and made no contact with C1 in the restroom. During interviews conducted LPA found, approximately 2 days prior to 9/14/2022, C1 slipped and fell on laundry basket due to an unsteady gait. Based on interviews conducted and document reviewed, LPA was unable to gather sufficient evidence to support the allegation above.

Although the allegation is valid or may have happened there is insufficient evidence to suppo rt the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of the report was provided to Tony Houston-RBT.