Complaint Investigation Report

During the first week, C1 was provided with auditory assistance, which required staff to remain close enough to listen for any requests for assistance from C1. By the end of the first week of assessment, it was determined that C1 required standby assistance, meaning staff were to be always within arm’s reach. The care plan remained unchanged until a revised Patient Program was implemented on 09/06/2023. The new Patient Program mandated that staff remain within visual proximity of C1 while in the home. When C1 was in the community, staff were required to provide standby assistance. A review of records did not indicate any falls occurring while C1 resided in the home. LPA's review of staff schedules showed that from 07/03/2023 through the beginning of September 2023, C1 consistently had 1:1 care throughout all three shifts each day. Interviews with six (6) staff members revealed that staffing levels were sufficient to provide 1:1 care, and no staff expressed concerns regarding the adequacy of care for C1. 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, “Staff did not address a client's change in medical condition” is deemed Unsubstantiated at this time.

It was reported that "Staff mistreated a client while in care" as it was alleged that Staff #1 (S1) did not appear professional or caring towards C1 when C1 was having a behavior episode. Interviews with six (6) staff members indicated that the standard protocol requires staff to give clients space when requested. However, depending on the client’s care plan, staff are required to remain within arm's reach or maintain visual proximity. In an interview, S1 denied ever failing to show professionalism or care towards C1. Additionally, interviews with other staff members revealed that they have never witnessed any staff member behaving unprofessionally or lacking care towards clients in their care. LPA records review of staff files did not indicate any instances of any staff displaying unprofessional behavior or lacking care towards clients. LPA conducted interviews with four (4) families or responsible parties of residents at the time of the complaint. All four (4) families reported that they had never observed any mistreatment of clients or witnessed any staff behaving unprofessionally or without care. Furthermore, none of the families expressed concerns about staffing at the facility. LPA attempted to contact Staff #2 (S2) and Staff #3 (S3) on 01/24/2024, 09/27/2024, 10/4/2024, and 02/12/2025, but was unsuccessful. 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, “Staff mistreated a client in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.