Complaint Investigation Report

9099C-1.. Allegation: Staff did not ensure resident was safe from other resident. The allegation notes that on May 1, 2026 (8:40 am), client (C1) became very upset upon hearing clients (C2/C3) having a private conversation behind (C1), while being transported to day program. (C1) became upset due to believing (C2/C3) were talking about (C1), who then began yelling and trying to strike (C2) from the front seat.

Both day program staff, including the driver of the van during the incident on May 1, 2026, stated that they have never observed (C1) to become physically aggressive with anyone, but only previously observed (C1) to be verbally aggressive/yelling at another day program participant. The drive confirmed he previously met all (3) clients (C1/C2/C3) at day program and May 1, 2026 was the first time he transported these clients. The driver stated to LPA, "when (C1) started getting upset, I attempted to redirect (C1) but (C1) did not listen". The driver also stated he immediately called his boss on the bus radio when (C1) started hitting (C2) while seated in front of (C2/C3). The driver stated he could hear (C2/C3's) conversation and there "nothing slanderous or rude regarding (C1)- they were exchanging stories about their week, but it's set in (C1's) mind that they were gossiping about (C1) , and it was impossible to redirect (C1)".

Clients (C2/C3) stated that (C1) has never shown physical aggression before and this year has been the worst ever. The Ombudsman also interviewed clients (C2/C3) who indicated "(C1) has never been physical before the May 1, 2026 bus incident". (C1's) IPP, dated November 26, 2025, notes (C1) participates in behavioral consultation due to self-injurious behaviors and inappropriate social behaviors that may result in emotional outbursts and fights that occur weekly and require staff intervention. The IPP also states that (C1) has an increase in anxiety and depression and will call 9-1-1 during the springtime.

The Licensee stated that during every spring season (C1) exhibits various behaviors, including arguing with house mates and calling 9-1-1 to go to the hospital. (C1's) charting notes and incident reports submitted to the department, starting on/around March 2026, reflect multiple incidences. (C1) has continued to attend medical appointments with their care provider and Advanced Psychiatrist for monitoring and medication changes. The Licensee stated (C1) has shown "verbally aggressive behavior a number of times before" but never any physical aggression. The driver of the van stated , "I made every attempt to de-escalate and re-direct, but it didn't work- I had to make an emergency stop."

Based on information obtained, and that this incident occurred while (C1/C2/C3) were being transported by day program staff, and not at the facility, the allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurre d.