Complaint Investigation Report

Regarding the allegation “Staff are not properly trained”, it was reported License Vocational Nurse (LVN) LaTonya Turks was conducting a staff training on 03/13/2024 when Turks noticed C1 needed to be repositioned while sitting on a beanbag chair. Turks informed S1 to reposition C1. S1 grabbed and pulled C1’s arms to reposition. Turks immediately stopped S1 and informed S1 not to reposition C1 that way. S1 then grabbed C1 by the neck to reposition C1 on the chair. Turk instructed S1 to stop what they were doing and informed them to use C1’s gait belt to reposition. Interview with staff revealed S1 has been redirected multiple times on how to properly handle C1 or other clients but S1 does not listen to their instructions. Interviews with staff revealed on 03/13/2024, C1 had fallen on the couch due to S1 not utilizing the gait belt correctly while walking with C1. Two staff members present had to assist C1 getting up from the couch. Interview with Supervisor Hamilton revealed S1 was trained on how to utilize the gait belt for S1 but there is no written documentation of S1’s training on how to use the gait belt. Hamilton stated before S1 can conduct one on one care with C1, S1 will need to be trained on how to use the gait belt properly. The facility will conduct an all staff training on body mechanics, transferring individuals, and gait belts. Therefore based on interviews and record review, the allegation “staff are not properly trained” has been deemed substantiated at this time.

A finding that the complaint is SUBSTANTIATED means the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated means that the allegation(s) is valid. A citation is being issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 3) on the attached 9099D.

An exit interview was conducted, and a copy of this report was given to Hamilton along with the LIC 9099-D, LIC 811, and appeal rights.