Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not provide adequate supervision for client resulting in client sustaining a fall.

The detail of the complaint alleges that C1 was not assisted while walking which resulted in a fall at the day program. C1 allegedly missed a step and fell on his back.

On February 12, 2026, at 9:30am, the Department interviewed the Licensee (A1) who denied the allegation stating that C1 was accompanied by staff when he fell however C1 stumbled due to his unsteady gait and fell backwards. According to A1 the staff assessed C1 and did not see any visible injuries at the time of the incident. A1 further stated that the protocol for when a client falls is to 1) assess the client for injury, 2) apply first aid if needed 3) call 911 if the injury is serious, 4) call client’s home 5) submit and incident report.

On February 12, 2026, between 9:30am and 10:30am the Department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied allegation, stating that due to C1’s unsteady gate C1 is always accompanied by staff while at the program. Lastly, 5 out of 5 staff where able to state the protocol of what to do when a client falls.