Complaint Investigation Report

claimed the staff pushed them. One additional staff who was a witness corroborated this story. Two staff also described the following additional bruises or injuries on R1: a bruise on R1’s buttocks from falling off their bed and swelling on R1’s shoulder from a COVID-19 Booster and Flu shot. LPA reviewed a facility body check dated 10/05/22 which describes a bruise on the shoulder and a body check dated 10/12/22 which describes a bruise to R1’s buttocks. LPA interviewed two residents who were present and could communicate, both stated they have never been hit or pushed by staff, that they do not have any problems at the facility and do not have any injuries. One of these residents corroborated that R1 had been pushed while the other did not. LPA conducted health and safety checks on four residents present, observed no health and safety issues, but did observe multiple small bruises on R1’s upper arms that looked like pressure points from hands and fingers. LPA interviewed R1 who denied ever being hit or pushed by staff, stated that the bruises on their arm were from a fall on the street and the bruise on their buttocks was from falling off of their bed. One staff explained the bruises on R1’s arms as resulting from staff trying to help get R1 out of the facility van after a trip to Sea World, as R1, due to their disabilities, was stuck in the van and was “not helping [themselves] to get up” and it took 20 minutes for the 5 staff to help R1 get out of the van. LPA reviewed the facility care notes which state that on 10/06/22 R1 had pain on their shoulder from the vaccinations; on 10/08/22 R1 fell off of their bed; on 10/11/22 R1 became upset, tried to pull the bookshelf down, the bookshelf would have fallen on another resident, a staff held the bookshelf up, during the struggle over the bookshelf R1 fell, and R1 accused the staff of pushing them; on 10/13/22 R1 fell down in the bathroom; on 10/13/22, during a trip to Sea World, R1 became stuck between the chairs of the van and the staff had a hard time helping R1 because R1 was not helping themselves get unstuck; on 10/14/22 R1 was observed to have multiple bruises from the van incident on 10/13/22. LPA reviewed R1’s Individual Program Plan dated 08/04/22 which states that R1 leans toward their right when sitting and needs supervision to ensure they do not fall, that R1 has limited safety awareness skills and requires support to ensure they remain safe in all settings, and that R1 is monitored for the following behaviors: temper outbursts, physical aggression, self-injurious behaviors, false statements, and property destruction. LPA has met R1 multiple times and has observed R1 to have an unsteady gait, difficulty with fine motor skills, and to have poor balance. While R1 may not have been pushed by staff and while R1 may be accident prone, R1 has sustained multiple bruises both from staff handling and from R1’s lack of balance and the facility should be taking additional measures to track and address R1’s falls.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been