Complaint Investigation Report

Interviews consistently established that while C2 was carrying the bowl of hot soup, C2 came into contact with C1, causing the hot soup to spill onto C1. As a result, C1 sustained second-degree burn injuries. Facility records reviewed by LPA were consistent with statements obtained during interviews regarding the circumstances of the incident and the injuries sustained by C1. Based on interviews and records reviewed, LPA determined that staff failed to provide adequate supervision during meal service. The preponderance of the evidence established that the lack of active supervision allowed C2 to independently carry hot food when staff acknowledged C2 should not have done so. This lack of supervision directly contributed to the incident in which C1 sustained second-degree burns. Based on the evidence obtained during the investigation, the allegation that facility staff failed to provide adequate supervision, resulting in C1 sustaining second-degree burns, is Substantiated. A finding that a complaint is substantiated means there is a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Program Manager Danielle Edwards. This report, appeal rights, and the attached LIC 9099-D were discussed and provided at the conclusion of the visit.