Complaint Investigation Report

The investigation reveals the following: Regarding " Facility staff hit resident.”. It is alleged that staff hit C1 on the head. During the visit LPA interviewed the administrator. The administrator denied the allegation stating, C1 attempted to AWOL and ran into the gate. Per administrator C1 has a history of self-injurious behaviors and fabrication. 3 out of 3 staff stated they have witness C1’s self-injurious behaviors and fabrication. 1 out of 3 staff stated they witnessed the incident of C1 trying to elope and hitting their head on the pin box at the gate. 1 out of 3 clients stated they are ok, and no one hurt them. The clients case manager stated the situation is part of the client’s behaviors that they are working on improving. LPA reviewed documentation and observed client has a history of fabrication and self-injurious behaviors.

The investigation reveals the following: Regarding " Staff do not administer resident's medication as prescribed.”. It is alleged that C1’s drug screen was negative for Lorazepam. During the visit LPA interviewed the administrator. The Administrator denied the allegation stated C1 always takes their medication. The administrator further stated there are rare times C1 refuses to take their medication but has always come back and took their medications as prescribed. 3 out of 3 staff denied the allegation, stating that C1 do not have a problem taking medications. 1 out of 3 clients did not want to talk about their medications. The Case Manager stated C1 do not have any issues taking medications. LPA reviewed C1’s MAR and did not observe any discrepancy.

Based on LPA's interviews, and file review the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Angela Williams and a copy of this record provided.