Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not prevent a client from threatening other clients

It is alleged that facility staff have failed to address a client who threatens to stab or hit staff and other clients with a pen, backpacks, and water bottles. LPA interviewed 5 staff and each denied the allegation, staff stated that the facility is a behavioral program and although this may have happened as clients exhibit behaviors, the behaviors are addressed, documented, and meetings with the behaviorist, the clients service coordinator and facility staff are conducted to develop a plan on how to decrease these behaviors. LPA interviewed 5 clients and each denied the allegation, C1-C4 shared that they have either been hit/pushed by another client or a client has attempted to hit/push them but staff separate that client from the group and talk to them privately. Each client stated they feel safe at the facility.

Allegation: Staff are falsifying documents

It is alleged that S2 and S3 falsify documents and SIR’s (mostly regarding injuries) to protect other staff. LPA interviewed 5 staff and each denied the allegation. Interview with S2 revealed that when SIR’s are created, information from both the ISP Data Collection (information documented by staff that witnessed the incident) and statements provided during investigation are what is documented on the reports. LPA reviewed SIR’s and ISP Data Collection, the information documented appeared to be correct and not missing any information.

Allegation: Staff inappropriately took pictures of clients

It is alleged that S4 has taken inappropriate pictures of clients. LPA interviewed 5 staff and each denied the allegation, staff stated that the only time they take photos of clients is either during intake/admission for their Face Sheet or when an injury is observed, staff stated that these photos are for documentation only and none of the photos are inappropriate. Staff also stated that clients are asked for permission prior to taking their photo. S4 denied the allegation and stated that they have only taken photos for clients face sheets or injuries, photos of injuries will accompany a body mark form to explain the injury. LPA interviewed 5 clients and each denied the allegation, each client stated they are asked if its ok to be photographed, they don’t mind and that the pictures are not inappropriate.

Allegation: Staff inappropriately shared pictures of clients

It is alleged that S4 has sent inappropriate pictures of clients to old managers. LPA interviewed 5 staff and each denied the allegation, staff stated that the only time they take photos of clients is either during intake/admission for their Face Sheet or when an injury is observed, clients are asked permission to take photo, these photos are for documentation only and not shared with others. LPA interviewed 5 clients and each denied the allegation, each client stated, they don’t mind being photographed, the photos taken are not inappropriate and don’t know if the photos are shared with anyone. (Continued on LIC9099-C)