Complaint Investigation Report

LPA requested and obtained copies of the following documents: Register of Facility Clients (LIC 9020), Personnel Report (LIC 500), clients’ Individual Program Plans (IPP), Daily Logs, Special Incident Reports (SIR) for the date in question, along with the schedule and a client’s Individualized Support Plan (ISP). At 3:44 p.m., LPA interviewed a client's family member that witnessed clients behavior outside of the facility.

Allegation: Staff pushed resident. It was alleged that staff pushed a resident to the ground on Sunday, 2/08/2026. LPA's interview with two (2) clients revealed that they had not been pushed by staff, nor had they witnessed staff push another client. Interviews with staff who were present on Sunday, February 8, 2026, revealed that during the afternoon shift three (3) clients wanted to go out. Staff asked clients to wait until the next shift so that everyone could go to the same location as there was only one car available. This led one (1) client to become upset, which then triggered similar reactions from the other (2) clients in the facility. According to staff, two (2) clients ended up outside in the neighborhood. One (1) client was being verbally aggressive, hitting cars, and the other client was hitting a staff. During the incident, two clients experienced falls outside the facility. Both clients corroborated that their falls were not the result of being pushed. Staff denied pushing any clients or witnessing other staff push clients. LPA’s review of the Daily Logs and Special Incident Reports (SIRs) corroborated staff statements. Additionally, LPA’s review of the Individual Program Plan (IPP) for the (2) clients who were outside revealed that the clients may have episodes of yelling and verbally aggressive outbursts, which is consistent with the behaviors described by staff. However, only one client's IPP indicated they would become physically aggressive. Staff reported that they had not witnessed the clients be physically aggressive while at this facility.

Based on interviews and record review there is insufficient evidence to support the allegation, staff pushed resident. 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.