Complaint Investigation Report

It was alleged that on December 10, 2024, C1 was observed with a “black bruise mark” on their face, that this was the third time C1 had sustained this kind of injury, and there is concern that C1 is being physically abused. LPA inspected the facility, conducted health and safety checks on all four clients, observed no health and safety issues, and observed no visible injuries on the clients other than a small bruise on C1’s right upper cheek. LPA interviewed all four clients, three of whom denied that staff are hitting clients at the facility. C1 stated that S2 and another client at their day program hit them. LPA interviewed S2 who denied hitting C1. LPA reviewed S2’s staff file and did not obtain information corroborating the allegation. LPA interviewed the administrator of C1’s day program who denied that any incidents occurred at the day program that could have caused C1’s injury. Per client and staff interviews, C1 has also claimed that another client at this facility and other individuals at the day program have hit them in the past. LPA reviewed a facility incident report dated December 11, 2024, which states that on December 9, 2024, facility staff noted the bruise on C1’s face, C1 stated they were hit at their day program, and facility staff contacted the day program manager who stated that a day program staff had also seen the bruise but denied that any incidents occurred at the day program. LPA interviewed S1 who stated that S1 dressed C1 on the morning of December 9, 2024, and did not notice any injuries, but when C1 returned from day program that same day at 3PM, staff noted a bruise on C1’s right upper cheek, a photograph was taken, and C1 was seen by doctors on December 10, 2024 and December 12, 2024. LPA reviewed photographs of C1 taken December 9, 2024, and December 10, 2024, which show the scope of the bruise. LPA reviewed two facility incident reports dated December 5, 2024, which state that on December 3, 2024, at 3PM, C1 got into an altercation with C2 who hit C1 in the face with a sandal, and that on December 4, 2024, at 930PM, there was another altercation and C2 slapped C1 across the face. During the December 3, 2024, incident, three staff were present, and during the December 4, 2024, incident, two staff were present, and during both incidents staff intervened and redirected C1 and C2. LPA reviewed the facility’s communication log for December 3, 2024, and December 4, 2024, which document these two altercations. Per S1, C1 and C2 both have histories of aggressive behavior, the facility had the required number of staff during both incidents, facility staff intervened and redirected the clients based on their behavior plans, and the facility continues to work with the clients and their care teams to address aggressive behavior. LPA reviewed C1’s Individual Program Plan dated February 22, 2024, and C2’s Individual Program Plan dated November 28, 2024 which corroborate that these clients have known aggressive behavior and that their care teams are working towards decreasing incidents of aggressive behavior. The information obtained did not corroborate that staff caused C1’s injury.