Complaint Investigation Report

The Department was provided with photographs of C1’s wrist taken on 01/09/2026 and 01/22/2026. Review of photos taken on 01/09/2026 showed a small circular mark on C1’s wrist. In the photos, the wrist does not appear to be swollen, have redness, or indicate stages of bruising. Review of C1’s photos from 01/22/2026 did not show any apparent signs of being swollen or bruised.

Review of C1’s Behavioral Support Plan, dated 12/23/2019, stated C1 has a behavior of stopping and standing still without moving. Per report, this can last for as little as several minutes to several hours. Review of C1’s Individualized Service Plan (ISP) dated 03/04/2024 stated C1 can become frustrated during transitions onto transportation and can lead to aggression and resistance to getting onto the bus. Per C1’s ISP, C1 should have a minimum of 45 minutes dedicated to getting C1 prepared for transportation.

The Department conducted interviews with facility staff. Interview conducted with Assistant Director revealed that on 01/06/2026, C1’s responsible party reported to the facility that C1 had bruises on their arms from 01/05/2026. Per interview, on 01/06/2026, the Assistant Director conducted a visual assessment of C1's arms with their responsible party and observed a small red circular area on C1’s right wrist. This was identified by C1’s responsible party as a pimple. Interview further stated that facility staff denied any struggle, pulling, lifting, or inappropriate handling during bus boarding.

Interview conducted with Facility Nurse, stated that pictures of C1’s wrist were taken on 01/09/2026, and they did not observe any bruising or swelling on C1 at that time.

Interview conducted with Program Director stated that C1 has a behavior where they will stop moving which has led to struggles with transportation. Per interview, facility staff are to provide a time frame such as 5 or 10 minutes and counting to 3 to help with the behavior.

Interview with Staff Member 1 (S1) stated that C1 is a two person assist when getting on the bus, and that they never hold C1 by their hands or their arms. If C1 stops moving or doesn’t want to get on the bus, C1 is told that their friends are on the bus already or that their family is waiting for them. Interview further revealed that C1 is offered options and time for them to get on the bus.

Interview with Staff Member 2 (S2) stated that C1 is a two person assist when getting on the bus, but sometimes C1 only needs one staff member. If C1 stops moving or doesn’t want to get on the bus, staff are to wait and tell C1 that their family is waiting for them.

Multiple attempts to speak with Staff Member 3 (S3) were unsuccessful.