Complaint Investigation Report

Regarding the allegation, Staff member physically abusing client on the weekend, it was reported that on Sunday, August 11, 2024, Staff #1 (S1) and Staff #2 (S2) attacked C1 resulting in C1 sustaining scratches below the collarbone. Based on the interview with C1 on August 15, 2024, LPA observed superficial scratch wounds below both shoulders that appeared to be healing. Based on the staff and client interviews, it is unclear what caused C1 to become upset. However, S1 noticed that there was a dispute between C1 and Client #2 (C2) about the ice machine which triggered C1’s anger causing C1 to bang their head against the wall in the hallway in front of their bedroom. C1 indicated that they were grabbed by their t-shirt and was “restrained” on the floor by Staff #1 (S1) and Staff #2 (S2) because they were “acting out” and harming self. Nonetheless, C1 reported feeling safe living at the facility. The remaining three clients did not witness the incident, however one of the clients indicated that they heard the staff restraining C1 to protect C1 from hurting self. Based on the review of the staff records, S1 and S2 are certified with the Crisis Prevention Institute (CPI), which is an essential and mandated staff training to de-escalate and manage behaviors utilizing nonviolent techniques. Per interviews with S1 and S2, both denied the allegation of abuse. Both staff confirmed that S1 attempted to verbally redirect C1 from banging their head and scratching self. Both staff utilized CPI on C1 in an upright position in the middle of the hallway per S1 and S2. C1 calmed down and was eventually released from the position. Per staff interviews, S2 and S3 worked with S1 while the remaining three, (S4, S5, and S6), did not. Both staff reported S1 to be professional in conduct and respectful to clients. Based on the review of the Individual Program Plans (IPPs) dated October 26, 2021, and October 25, 2023, and May 3, 2024, C1 becomes easily upset and agitated, delusional in thinking, have identified aggressive behaviors such as scratching and banging head due to their diagnoses.

Regarding the allegation, Staff member uses marijuana on premises in front of clients, three out of three clients indicated not witnessing S1 and S2 smoking marijuana. However, C1 reported the marijuana smell was coming from outside while a second client indicated smelling the odor coming from S1’s clothes per interviews. S3, who reported working with S1 and S2, denied the allegation and has never witnessed S1 or S2 smoking marijuana.

The investigation revealed that there was insufficient evidence to corroborate the allegation that S1 and S2 had abused C1 as C1’s IPP reveals that C1 is delusional in thinking and bangs head and scratches in which the injury may have been potentially self-inflicted. Additionally, the allegation, staff using marijuana on premises in front of clients, was not corroborated as none of the clients witnessed S1 and S2 smoking marijuana.