Complaint Investigation Report

Allegation: Staff did not prevent client from causing self harm while in care.

During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Client #1 through Client #3 (C-1 through C-3). Staff interviews revealed that staff asked C-1 if C-1 was going to attend C-1’s day program on 06/09/22 (as the day program transportation had arrived) as C-1 woke up, took medications, had breakfast and returned to C-1’s bedroom. Per staff interviews, C-1 did not inform staff that C-1 was experiencing pain on the right thigh and did not ask for pain medication. Per staff interviews, staff do not refuse to give clients their medication. Per staff interviews, all medication disbursements are documented in a Medication Administration Record (MAR) which also includes pain medication. Staff interviews revealed that C-1 got upset when C-1 was asked if C-1 was going to attend day program. Staff interviews indicated that C-1 began to punch the walls in C-1’s bedroom quickly, threw coffee at the bedroom closet and was being rude (cursing) at staff. Staff initially attempted to redirect C-1 verbally and C-1 was getting more agitated and was talking to C-1’s self. Per Staff interviews, C-1 eventually followed staff redirection, got dressed and ready and left to the day program. Per Staff interviews, C-1 has a history of admitting self into a psychiatric hold (which C-1 proceeded to do on 06/09/22 while C-1 was at the day program). Client interviews revealed that they were inside their room when this incident occurred. Client interviews revealed that they have not witness anyone self-harming themselves in this home. Staff and client interviews do not corroborate this allegation.

Allegation: Staff did not treat client with dignity and respect.

During this investigation, LPA interviewed Staff #1 through Staff #3 (S-1 through S-3) and Client #1 through Client #3 (C-1 through C-3). Staff interviews revealed that all clients are treated with dignity and respect. Staff interviews revealed that on 06/09/22, C-1 was being rude and cursing at the staff. Interviewed staff indicated staff did not pull C-1’s comforter off him. Interviewed staff indicated staff are trained in client rights, mandated reporting, zero tolerance and crisis prevention intervention (CPI). Interviewed staff also indicated they have not witnessed nor received any complaints about staff not treating clients with dignity and respect. (2) out of the (3) interviewed clients indicated that staff always treat clients with dignity and respect. (2) out of the (3) interviewed clients indicated they have not witnessed staff mistreating clients. Staff and client interviews corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.