Complaint Investigation Report

Regarding the allegation that Facility staff physically abused a client , the following has been concluded: Client C1 was admitted to the facility on April 1, 2016 with a primary diagnosis of mild intellectual disability and epilepsy. On or around May 20, 2021, C1 sustained a bruise on his arm and initially stated that the bruise was sustained as a result of an interaction with an unspecified care provider, potentially at the partial hospitalization program C1 attends on weekdays. The presence of the bruise was confirmed upon inspection by the facility's duty nurse. However, per a review of C1's assessments, C1 is an unreliable historian due to a diagnosis of auditory and visual hallucinations. Based on statements made by facility staff and witnesses, the origin of the bruise could not reliably be evidenced to be the result of inappropriate staff action. Additionally, C1 is noted to have a history of self-injurious behaviors.

As a result, the allegation is found to be Unsubstantiated , meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.