Complaint Investigation Report

LPA Miller requested and was provided a tour of the physical plant. The LPA conducted a telephonic interview with the Administrator Jamie Smith and requested specific facility documents pertinent to the investigation. The LPA advised the Administrator that the investigation was assigned to Investigator Dennis Douglas, CDSS Investigations, and that further investigation was required.

On 02/11/2021, from approximately 11:30am to 1:00pm, Investigator Douglas conducted interviews with C1, staff, and clients; and on 03/11/2021, at approximately 6:30pm, with the reporting party. Additionally,

Investigator Douglas reviewed C1’s facility file which included a copy of the Individual Program Plan (IPP) Progress Report dated 03/02/2018; Behavior Progress Report dated 11/16/2020 for the review period of 08/01/2020 – 10/31/2020; and body check forms which documented various injuries observed on C1 for the period of 07/12/2020 through 02/02/2021.

The information revealed C1 has diagnoses of Mild Intellectual Disability, Epilepsy, and Schizoaffective Disorder. The IPP indicated C1 expresses “self-injurious” behavior causing injury requiring first aid or medical care. The Behavior Progress Report indicated 26 occurrences of self-injurious behaviors by C1 within the review period of 08/01/2020 – 10/31/2020. Those behaviors were noted as cutting, hitting self, jumping out of a moving vehicle as well as inserting items into mouth. Other behaviors noted were banging head, biting hand, throwing self on the ground out of wheelchair, and pulling own hair. The report also indicated that no injuries were reported.

During the course of the investigation, it was disclosed that C1 was observed with a bruise on face and swollen left pinky by C1’s Representative. C1 informed C1’s Representative that facility staff members hit C1 causing a swollen left pinky and bruise to face. However, when Investigator Douglas interviewed C1, C1 stated no staff members ever hit C1 and stated they self-inflicted own injuries because they were mad and no longer wanted to be at the facility. Facility staff, as well as other facility clients stated C1 exhibits behavioral issues in which C1 self-injures. S1 was interviewed and denied ever hitting C1 causing injury. S1 explained that they arrived on shift and observed that C1 already had a bruise on eye. S1 stated the staff member from the prior shift was already aware of the bruise and notified S1 of the bruise. It was believed that C1’s bruise was self-inflicted. S1 admitted not documenting the bruise because it appeared old. S1 explained they had not worked at the facility the entire week prior, so they presumed it had already been documented. When S1 was asked why C1 would make the claim that S1 hit C1, S1 explained sometimes C1 likes you, sometimes not.