Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not secure client in wheelchair leading to injuries during transport.

It is alleged that on 12/13/24 C1 sustained injuries while getting out of a transportation van that was operated by the day program staff and had bruising towards the area of her coccyx and elbow. LPA interviewed 4 Staff and each denied the allegation, interview with S3 revealed that while transporting C1 to their residence, once bus was put in part client unbuckled themselves from seat and threw themselves on the floor of the bust and hit their bottom, S3 stated that C1’s caregiver from residence was present at the time and witnessed the incident and after this incident there was special accommodations made to C1’s transportation where C1 is to use wheelchair during transport at all times. Interview with S4 revealed that C1 does have behaviors of pushing self-back and wanting to sit on the floor, S3 stated that even when assisting C1 into the transportation van C1 will push themselves back and try to take off their seat belt, therefore, two seat belts are always put on C1 for safety and C1 is always in wheelchair during transport. LPA interviewed staff from residence (W1) and staff confirmed incident, and stated that C1 does have a behavior of throwing themselves on the floor and did not observe any neglect from staff during this incident, staff confirmed regional center conducted investigation, this was unsubstantiated, and a plan was added to C1’s transportation where C1 is to be transported in wheelchair at all times to avoid C1 from injuring themself again. LPA interviewed 5 Clients, and each denied the allegation and stated they have not been injured during transportation/drop-off, 3 of the 5 clients interviewed use wheelchairs and each said that they are assisted into the bus and are assisted with seat belts and have never had any accidents or incidents during transportation from facility. LPA reviewed C1’s file and did not observe any note prior to incident that stated client must use wheelchair during transport. Due to C1’s self-injurious behaviors and no evidence of neglect or lack of supervision by staff pertaining to this incident, this allegation will be unsubstantiated.

Based on statements and interviews conducted with staff, clients, and witness, review of C1’s files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.