Complaint Investigation Report

On 06/20/23 LPA arrived around 10:26 a.m. LPA met with Staff 1 (S1) who contacted the administrator by telephone. LPA informed the Administrator, Moshood Ibrahim the purpose of the visit. LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. No issues or concerns were observed. From 10:55 a.m. to 12:10 p.m. LPA reviewed and obtained documents relevant to the investigation. At approximately 11:29 a.m. LPA interviewed Administrator, Moshood via telephone. Client#1 (C1) arrived at 1:30 p.m.; by 2pm second shift staff arrived. LPA interviewed three (3) staff and four (4) out of four (4) clients from 12:10 p.m. to 2:30 p.m. Additional relevant documents to the investigation were requested from the administrator. On 04/10/24 LPA interviewed two (2) more staff present during the incident in question. During interviews for the investigation, three (3) staff and the administrator, confirmed that C1 will act out and has behavior issues of self-harm including hitting self and banging head. C1 will also attack the staff including kicking and spitting at staff. Four (4) Staff interviewed that were present during the incident in question stated that staff did not see any staff, throw C1 to the floor causing any harm including bruising, nor have any of them, thrown a client down to the floor. Staff state they have protected C1 from self-harm and attacks to staff from C1, staff with crisis prevention training have blocked or held C1 back to prevent injury. Three (3) of the four (4) clients interviewed about this allegation and incident deny seeing C1 being injured by staff, but confirm that C1 does act out, yelling, banging things, hitting herself and throwing things. C1 was the only client of the four, who states staff #2 (S2) threw C1 to the ground causing bruising to C1’s arm. Four (4) clients, five (5) staff and the administrator confirmed C1 is not happy at this facility and that C1 wants to leave, C1 has told some of the facility staff and other facility clients that she wants to move to another facility. One of the four clients reported that C1 does not act this way at the day program they attend. C1 only acts up when C1 gets to the facility. The administrator, three (3) staff and four (4) clients confirmed that C1 did call 911 on the date of this incident, and the police came to the facility. Police did interview C1 and staff. All interviewed confirmed, the police did not see any health or safety concern when they arrived at the facility, therefore no action was taken on that day of the incident. One of the staff stated that after the incident C1 reported to staff #4 (S4) that C1 lied about S2 hurting C1.

Based on interviews conducted, there is insufficient evidence to support the allegation that resident was injured by staff. Therefore, the allegation is Unsubstantiated. Exit interview conducted, a copy of this report was signed and delivered.