Complaint Investigation Report

During the CPI hold, staff and R1 fell, resulting in R1 sustaining bruises. Further information obtained from interviews with additional staff indicated they do recall the incident and staff did not assault R1. It was explained that R1 was not complying in the CPI hold and staff and R1 fell. After multiple attempts, LPA was unable to contact and interview R1 due to several facility relocations and attending home pass visits over the weekend. Information obtained from interviews with residents stated there were no concerns regarding staff being physically aggressive with residents. Information obtained from additional witness stated R1 returned to the facility from the hospital and there were no documented injuries included in the hospital discharge documentation.

LPA’s review of the records demonstrated there was documentation of an attempted CPI hold on the date and time of incident in question. Additional record reviews confirmed R1 did go to the hospital on the listed date and time, but there were no noted injuries discussed in the hospital discharge orders.

Based on interviews, record reviews, observations, and the inability to interview relevant parties, the allegation that staff physically assaulted resident which resulted in injuries is unsubstantiated. Information obtained was not sufficient to support the listed allegation. Although the allegation may have happened, there is not a preponderance of the evidence to determine if the alleged violation did nor did not occur.

An exit interview was conducted, and a copy of this report was discussed and provided to Natanael Hernandez, Administrator.