Complaint Investigation Report

The investigation revealed the following: in regard to the allegation "Staff is verbally abusing a client while in care", it is alleged that the client is being verbally abused by facility staff Interviews conducted with the Licensee, Admin, and two (2) out of two (2) staff denied the allegation and stated that C1 gets verbally and physically aggressive towards staff as a way to get to the hospital and when C1 is out of P & I funds (Personal and Incidental) . LPA observed C1’s IPP and Behavioral Quarterly Report which indicates C1’s behaviors of fabricating stories and false accusations. Two (2) out of four (4) clients corroborated with the allegation of verbal abuse but could not provide specific examples of the alleged abuse, nor the time and dates that the verbal abuse occurred. Based on record review, client’s notes dated 05/07/2025 indicated a client yelling at staff when asked to change clothes, fighting with another client, was in an aggressive mood throughout the day but was stable after client went back to the client’s own room. Two (2) out of four (4) clients denied the allegation. Three (3) out of three (3) witnesses denied the allegation and do not suspect any client being verbally abused by staff. LPA also reviewed ongoing staff training on zero tolerance, client rights, abuse and neglect prevention, and personnel policies. Licensee and Admin both stated that there have been no disciplinary actions issued to any staff regarding verbally abusing a client. Based on interviews conducted with facility staff, facility client, witnesses, and record review, there was not enough supportive evidence to concur with the reported allegation.

Allegation: “Staff kicked a client while in care.” It is alleged that a facility staff member kicked the client on the stomach multiple times. Interviews conducted with the Licensee, Admin, and two (2) out of two (2) staff denied the allegation and indicated that they have never kicked nor witnessed any other staff kick or hit C1 in the stomach. Four (4) out of four (4) clients denied the allegation. Per facility client notes dated 05/07/2025, C1 was not punched by another client, and instead it was reported that C1 was upset and yelling until staff intervened and deescalated the situation around 5pm. Based on record review, LPA observed C1’s IPP and Behavioral Quarterly Report which indicates C1’s behaviors of fabricating stories and false accusations. Interview with W1 also indicated that C1 has a history of fabrication and making false accusations. LPA interviewed three (3) out of three (3) witnesses denied the allegation and do not suspect staff kick or hitting any clients. LPA obtain copies of ongoing staff training on abuse and neglect prevention and zero tolerance policy. Licensee and Admin both stated that there have been no disciplinary actions issued to any staff regarding physically abusing a client. There is not enough supportive evidence to concur with the reported allegations.