Complaint Investigation Report

Allegation: Staff did not properly report an incident involving a client

Relevant party reported that the facility did not report when R4 went missing or AWOL from the facility. According to interviews with the Administrator, S1, S3, S4, S5, S6, and S7, the incident did not occur. No incident was reported to the Department.

Allegation: Staff did not have planned activities for the clients

During visits conducted on 10/24/24 and 1/17/25, LPA observed resident’s (R1, R2, and R3) and R4’s weekly activity calendars and daily programming outlines, which indicated what the residents will be doing throughout each day of the week. According to R1, R2, R3, and R4’s Individualized Support Plans for December 2024, all residents participated in activities throughout the month. Interviews with Administrator, S1, S3, S4, S5, S6, and S7, indicated that all residents go on outings and participate in activities frequently. Relevant party reported that R4 is taken on van rides and falls asleep while staff continue to drive around. Interviews with S4 and S7 indicated that, if a resident falls asleep on a van ride, they take the resident home. Interviews with S1, S4, S5, S6, and S7 indicated that they have never witnessed R4 fall asleep on a van ride. Staff interviews also indicated that all residents are alert while in the van.

Allegation: Staff do not ensure a client is properly fed

Relevant party reported that R2 is missing meals and has gone days without food. Interviews with Administrator, S1, S3, S4, S5, S6, and S7 indicated that R2 is provided meals and is eating. Interviews also indicated that R2 tends to eat more food during the NOC shift and is eating daily. Staff indicated that, although R2 eats more during the NOC shift, they are provided three meals a day and snacks throughout the day as well.

Allegation: Staff did not seek timely medical attention

Relevant party reported that a resident (unknown) was in a car accident, hit their head, and was not taken to receive medical treatment. Interview with the Administrator indicated that there have not been any car accidents since they have worked at the home. Interviews with S1, S3, S4, S5, S6, and S7 indicated that none of the residents were involved in any car accidents. No incident was reported to the Department.

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