Complaint Investigation Report

In addition, LPA requested copies of the following for Client #1 (C1): Eviction notice, Physician's Report, Appraisal/Needs and Services Plan, Hospital discharge paper, and Police report. During today’s visit, LPAs toured the facility and interviewed additional 2 Staff and 3 Clients.

The investigation revealed the following:

A llegation – Facility staff unnecessarily sent client to hospital. It was alleged that Client #1 (C1) was sent to the hospital under false pretense of alcohol and polysubstance abuse. Based on interview with the Assistant Administrator, C1 was sent to the hospital due to yelling, screaming, and wanting to hit the Administrator. C1’s mother was contacted and agreed for staff to send C1 to the hospital. Per the Administrator, a client is sent to the hospital because immediate medical attention is needed and which he spoke with the C1’s doctor who recommended for the client to be sent to the hospital. He stated that C1 was displaying a danger to self and others at the facility due to the increase erratic behaviors that were presented more recently. At the hospital, C1 was tested for substance abuse which results were negative. However, hospital assessment showed that C1 was having suicidal ideation. There is insufficient evidence to show that C1 was sent to the hospital for unnecessary reasons.

Allegation - Facility staff did not notify client’s authorized representative of unusual incidents. The Assistant Administrator stated that she would normally contact C1’s responsible party when unusual incidents occur. However, if she is not available to do so, Administrator Barrios would make the call. Per Administrator Barrios, he stated he was often in contact with C1’s mother to notify of C1’s increased aggressive behaviors. As indicated on the eviction notice dated 10/5/20 and incident reports, C1 went after a staff with a knife and tried to hit the Administrator. Mr. Barrios stated he informed C1’s mother of the incident and was one of the reasons for the eviction notice served. Based on information obtained, there is insufficient evidence to corroborate this allegation.

Allegation - Facility staff speak inappropriately to client. According to interviews with staff, they denied speaking inappropriately to clients. Staff have training on client’s rights and stated that they do not make fun, use vulgar words, or talk badly about the clients. They have not heard any other staff speaking inappropriately to clients either. 8 out of the 10 clients interviewed stated that staff have not spoken to them inappropriately. Some said that the staff are respectful, nice, and helpful.