Complaint Investigation Report

*9099C-1... Allegation: Staff did not prevent a resident from assaulting another resident in care. The allegation states client (C1) has been hit, punched, and kicked by another resident(C2) in the common areas, (R1’s) room and in the shower and that staff are not doing enough to protect (C1).

Facility staff interviews indicated that no one saw the incident that was alleged to have occurred on November 8, 2024 (9:00 am). Both staff also indicated they have never heard or observed (C2) to engage in any physical contact with other residents during the many years (C2) has resided at their care homes. The Administrator stated this is the first time (C1) has bullied (C2). Both staff also indicated (C1)has previously shown this same behavior, including bullying other clients at the residence and day program, and meets with their Behaviorist two times each month.

A lead care staff who was present during the alleged incident sta ted there was no injury to client, (C2), after client, (C1) placed their backpack on (C2's) feet, adding client, (C2) likes to rest on the front couch often. This staff explained that (C1) came to the kitchen and told her (C2) had kicked them and that (C1) reported it already to the day program. This staff stated "(C1) bullies (C2)" and stated there have been ongoing problems with (C1 and C2) as (C1) doesn't like (C2) walking around as (C2) feels (C1) is "very bossy", commenting (C1) will often "bullies the lower functioning" clients.

(C1) stated to LPA on 11/12/24 that (C1) set their back pack on the couch next to (C2), who was laying on the couch. (C1) stated "(C2) doesn't like anything near (C2)" and asserted "(C2) is violent - (C2) kicked me and slapped me at the kitchen table later on the same day, just to be mean and hateful". Client (C2) stated on 11/12/24 they recall the incident and "(C1)told me to get out of the couch" and indicated they (C2) kicked (C1) but neither was hurt. (C2) has a diagnosis of Dementia, is able to walk without a walker and is more frail than (C1).

(C1's) prior Service Coordinator stated she doesn't know anything about the alleged incident but only knows (C1) from previously working with them, explaining (C1) "has a documented history" of saying people are being mean and bullying her. The current Service Coordinator confirmed there was a quarterly meeting held on 11/18/24 and this alleged incident was discussed. (C1) stated during the meeting that (C1) placed her backpack on client (C2's) feet, while (C2) was laying on the couch. (C2) then moved her feet from under the backpack and kicked (C1). The Service Coordinator stated it was concluded during the meeting that the alleged incident was not "physically possible", as (C2) needs a lot of physical assistance and is very "fragile", and that this was very likely a "misunderstanding" and no physical contact was made.