Complaint Investigation Report

Allegation: Staff did not report incidents to licensing.

It was reported that staff members who report suspected client abuse, neglect, or other serious incidents are terminated or intimidated shortly after making those reports. Additionally, the complaint report included that staff failed to submit required special incident reports to Community Care Licensing (CCL) when clients had visible injuries. To investigate this allegation, LPA conducted interviews with the Administrator, LVN, three (3) DSP/ caregivers, and one (1) client who was able to communicate. Interviews with the Administrator and staff indicated that staff are trained to notify the on-duty LVN of any incident or injury and to complete an incident report. The administrator stated that required incidents are reported to CCL and Regional Center within the required time frames and that an incident log is maintained. Staff interviewed were able to describe the reporting process and denied being told not to report or to alter documentation. Staff also stated that they had personally completed incident reports and that management submitted them to the appropriate departments. Staff interviewed denied being retaliated against for reporting and stated they would feel comfortable contacting CCL or Regional Center if they believed concerns were not addressed properly. Due to lack of client identifying and specific incidents information, LPA reviewed the facility’s resident roster, unusual incident reports, and logs for the past sixty (60) days to determine whether any client had incidents and ER visits. Records show that multiple incidents happened and some clients experienced episodes during this period. For those clients, documentation reflected that staff assessed the clients after each incident, notified the responsible party and/or physician as appropriate and sought emergency medical care when indicated. Records also showed in-service/training was provided to staff members covering: Mandatory reporting, neglect/preventing abuse, etc. Client interviewed reported that staff assist them when they need help and did not report that staff failed to respond after an incident. Because there was no specific incident, staff member, or client, that could be tied to the complaint, also records review and interviews did not reveal evidence that staff failed to report incidents to licensing, there is insufficient evidence to corroborate the allegation. Therefore, the allegation is Unsubstantiated at this time.