Complaint Investigation Report

It is being alleged that staff was observed transferring C1 without a gait belt. During the investigation LPA obtained digital evidence of the reported incidents. LPA reviewed the evidence and observed one (1) staff assisting C1 with transferring; C1 didn’t have gait belt on.

On 8/9/2022 LPA conducted client file review: Per Individual Service Plan review dated: 3/10/2022: Diagnoses: Mild intellectual disability, cerebral palsy, epilepsy, traumatic Brain injury secondary to auto to auto motor vehicle accident. Administrative team has been working diligently with medical doctor and health insurance to get authorization for continue therapy. Walker provides support with walking. “C1 should have on a gait belt for staff to support while another staff walk behind in case C1 needs to sit down.” Per Individual program plan (IPP) dated 1/06/2020 C1 has a goal to walk 15 to 20 feet to and from the bathroom with two person assist and a gait belt as gait is unsteady. Risk assessment: Are there any identifiable risks present? Yes; C1 ambulates with an unsteady gait and experiences seizures at times making more prone to falls. Risk is noted as: Falls Intervention: gait belt, staff assist. Per Physical therapy daily notes dated: 2/08/2022 Current complaints/ impaired standing, gait difficulty, risk for fall. C1 suffered traumatic brain injury and showed weakness….impaired standing, difficulty with functional mobility and gait difficulty. Patient Problems: Moderate assistance with mobility and transfers, moderate assistance of two person with gait training.

Per interviews with clients, LPA was unable to obtain clear accurate statement due to intellectual disability. Per interviews with Licensee, Administrator, and staff it was communicated to LPA that C1 utilizes gait belt for support, staff are trained in safety utilizing gait belts and C1s needs and service plans are followed.

Based on LPA’s observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 8/9/22 LPA reviewed C1 service plan and it is documented that C1 should have on gait belt for staff to support. LPA obtained digital evidence that staff were not utilizing gait belt while assisting client with transfers. Therefore, the allegation, is found to be SUBSTANTIATED . California Code of Regulations, Title 22 are being cited on the attached LIC9099-D.