Complaint Investigation Report

Allegation: Resident had access to a sharp object while in care..

It is alleged that resident had access to a sharp object while in care.

Client (C1-C3) were interviewed and clients (C2-C3) were unable to discuss specific questions at the time. Client (C1) stated she likes it at the facility and gets along with everyone and stated her favorite staff is “all of them”. Client (C1, C3) stated they do help cook and prepare meals. Client (C1) stated she “grabbed knife” from staff (S2). Staff (S2) stated staff (S2) was not expecting her to grab out of staff (S2) hands while staff (S2) was cutting vegetables. Client (C1) engaged in self-injurious behavior at that time and proceeded to self-inflict injury in her abdominal area. Staff (S2) immediately deescalated the situation and staff (S1) helped secure the knife away from client (C1). Staff immediately called 911 and administered first aid to the wound. Administrator and staff (S1-S2) stated when clients are helping prepare meals, clients never have access to sharp objects while helping preparing meals. Administrator and staff (S1-S2) stated the staff always handles the sharp objects when preparing meals. LPA observed all sharps locked at the facilities during visit on 2/17/2022 and 05/02.2022. LPA reviewed documents for training for Uniform Emergency Response Training, CPI Crisis Development Model, Care welfare safety and security, behavior levels leading to a crisis, verbal and non-verbal techniques to prevent acting out behaviors and client (C1) behavior escalation training.

Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met . 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 allegation is Unsubstantiated.

An exit interview was conducted with Administrator Demetra Walker, and a hard copy was provided.