Complaint Investigation Report

Interviews and record reviews indicated that C1 was unaware of how they sustained a cut, and facility staff only learned of the injury when C1 disclosed it during a scheduled visit with Regional Center staff. During this visit, C1 showed the cut and requested first aid. The cut measured approximately 2 to 3 inches long, was deep, scabbed, and inflamed. Facility staff provided immediate care for the wound, stating they were unaware of it because it had been covered by C1's clothing. A review of C1’s Individual Program Plan (IPP) dated July 26, 2024, noted that C1 requires verbal prompts and occasional physical assistance to initiate and complete activities of daily living (ADLs) such as bathing, grooming, dressing, and personal hygiene. C1 is verbal and can effectively communicate their needs and desires, including feelings of pain and discomfort, and can seek assistance from caregivers. Physician's report dated July 25, 2024, indicated that C1 does not require assistance with bathing, grooming, dressing, or toileting. Interviews with staff and C1’s family revealed that C1 tends to scratch themselves due to having dry skin. Staff have been reminded to encourage C1 to apply lotion to dry areas of skin. C1's family, the Community Support Specialist (CSS), and the Service Coordinator (SC) did not express concerns about staff causing the injury and confirmed that once staff were informed of the cut, they provided first aid promptly. A review of the staff schedule revealed there is at least two (2) caregivers scheduled per shift. During physical plants LPA observed C1 to freely move around the home with staff nearby. On 10/08/2024, at approx 12:02 p.m. LPA observed what appeared to be a healed scratch on the top of C1's left arm between the elbow and wrist. The scratch appeared to be the width of a finger nail and approx not more than 2 inches long. LPA's interview with C1 revealed they scratched their arm because it was itchy. LPA observed staff prompting C1 to pat the itchy area rather than scratch. LPA's interview with two (2) other clients in care during the time of the complaint revealed they have never observed staff cause harm to any clients in care and they did not express any concerns for staffing at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “resident sustained an unexplained injury while in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.