Complaint Investigation Report

Allegation: Resident sustained unexplained injuries. It is alleged, that client #1(C1) sustained unexplained injuries. During the investigation, through documentation and interviews on the dates noted above it is stated that C1 has self-injurious behavior. This was observed in C1’s client records and the Needs and Service plan. It was observed that C1 was expressing aggressive behavior on 03/05/22 at the facility, as well at the hospital stay of 03/05/22. In the Needs and Service plan it states C1 hits himself and falls to his knees. It was reported in interviews with C1’s CSC, other clients, and staff that C1 was seen to expresses behavior episodes of self-harm by falling to the ground, falling backwards, and banging his head on the wall, they stated it was done for attention or to get his way, or when he gets upset with staff. Staff report that C1 has punched holes in walls during aggressive episodes. Five of the five staff interviewed denied they hurt C1. Staff stated that when C1 has a behavior incident and becomes aggressive with staff or other clients, CPI training technics are used, like putting client on the ground. Per Administrator Jessica Hernandez CPI is no longer used at the facility with clients, and when asked by the department LPA staff for proof of training, Jessica stated staff Henry Coleman no longer had a copy of the card to show proof of training. A review of the facility file was done to verify the training that would be required at this facility for behavior episode such as with C1. After the file review was conducted in Community Care Licensing office, there was no record found in the file that CPI training would be used, at the facility. Staff reported during interviews that C1 would try to tackle male staff. It was stated during interviews that staff were seen dragging C1 and at times C1 was dragged outside, to prevent him from doing stuff in the facility or to keep other residents away from him. It was reported in interviews that some staff are manipulative, and some staff will say certain things that trigger the clients.

In an interview with C1, he reported that the bruises on him during the 03/05/22 hospital stay were from staff hitting him and would kick him on his hips. He also stated when he would get upset at staff he would fall onto the ground onto his knees or backwards. In an interview with C1’s family member, it was stated, C1 told them, that C1 would be dragged whenever he would fall to the floor. On 03/05/22, C1 had an outburst with staff which caused C1 to break a window.