Complaint Investigation Report

Regarding the allegation: Staff restrained client in care resulting in multiple bruises. It was alleged staff did not implement proper Crisis Prevention Intervention (CPI) on C1 resulting in bruising. To investigate the allegation, LPA attempted interviews with four (4) clients and four (4) staff members. LPA attempted to interview C1, C2, C3, and C4 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S1 revealed the facility is only approved for, “…standing and sitting” Crisis Prevention Intervention (CPIs) holds. When questioned if C1 had ever been restrained by staff on the floor, resulting in bruising, S1 denied the allegation. When questioned if staff ever reported an improper CPI hold being done on C1 while on the floor, S1 stated, “No”. Additionally, S1 stated if C1 were to throw themselves on the floor the staff is to, “disengage”. When questioned if C1 had been observed with bruising prior to the complaint investigation, S1 stated they were made aware of C1 having a chest bruise but stated C1 could have possibly “self-injured” themselves due to becoming “super aggressive” while staff was conducting a CPI. When questioned if the bruise may have been caused by a CPI hold, S1 stated, “No there is no reason we would ever have bruising on the chest”. When questioned if they had submitted an Unusual Incident Report (SIR) regarding C1’s bruising, S1 stated, “No, it is my bad”.

However, LPA’s interview with both S3 and S5 confirmed C1 had been placed on a CPI hold while on the floor. LPA’s interview with S5 revealed they had conducted a hold on C1 while having them on the floor. When questioned as to why this was conducted, S5 stated they were told by a former staff member (S9) it was allowed. S5 stated the hold on C1 occurred sometime in October of 2025. When questioned if the improper hold resulted in C1 to have bruises, S5 stated, “No”. When questioned if S1 was made aware of the incident, S5 stated, “Yes”. LPA’s interview with S3 correlated with S5’s interview. When questioned if the incident involving C1 was reported to S1, S3 stated, “Yes”. LPA attempted to interview S9, but they no longer work at the facility and could not be contacted.

LPA’s supplementary record review of photographic images sent to Community Care Licensing Division, (CCLD) correlated with both S3’s and S5’s interviews. LPA’s record review of said images showcased C1 to be restrained on the floor by staff members. The images showcased C1 to be laying on the floor with their back against the tile floor. Additionally, S5 is shown to be physically restraining C1 by their legs using their arms and legs to wrap themselves around C1’s legs. Another two (2) unknown staff members are shown to be controlling C1’s upper body. Additional images provided to CCLD showcased bruising on C1’s arms and chest.