Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff are not treating resident with dignity and respect.

It is alleged that staff (S2 & S3) have spoken inappropriately to C1 and telling them that they are not a good person and have argued with C1 and their family. LPA attempted to speak with C1, however, C1 is no longer a client at facility and did not answer phone calls. LPA Truman was able to interview C1 during the initial visit on 10/15/24 and C1 stated during interview that S2 and S3 are nice, and have good intentions. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation, stating that C1 can be argumentative and aggressive, however, staff have never been seen, observed or overheard to be that way with C1. LPA attempted interviews with clients, due to cognitive disabilities LPA was only able to conduct 2 successful client interviews, in which both clients denied the above allegation and stated that staff are kind and treat them respectfully. LPA interviewed C1’s regional center service coordinator and they stated that C1 has history of being verbally aggressive with staff and family but have not heard or observed staff being verbally aggressive/argumentative with C1. The service coordinator also confirmed that C1 has not mentioned these alleged incidents during their in person review.

Allegation: Staff are not properly managing resident's medication.

It is alleged that C1 has been forced to take a medication that is not prescribed to them as it is medication for a diagnosis that they do not have. LPA Truman was able to interview C1 during the initial visit on 10/15/24 and C1 revealed that they do not take any medication and have refused medication. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that C1, upon admission, has refused to take medication. This is something that facility staff, service coordinator and family have been attempting to improve, however, there has been no success with medication or doctor visits. LPA reviewed medications and Medication Administration Record and did not observe any issues. LPA reviewed C1’s file and the medication that is allegedly not prescribed to them was listed in both the Physician Report and Regional Center documents. LPA attempted interviews with clients, due to cognitive disabilities LPA was only able to conduct 2 successful client interviews, in which both clients denied the above allegation and stated that staff help with medications and they haven’t experienced any issues with medication. LPA interviewed C1’s regional center service coordinator and they stated that C1 has been non-compliant with medication since before being admitted to facility and they have been trying to work with C1’s family and facility to become medication compliant, with no success as of yet.