Complaint Investigation Report

On 11/10/21 C1's fall resulted in bruising to the left side of his head and the left side of their body. C1 sustained two falls on 11/11/21 which resulted in bruising to right shoulder and the left side of their head. On 11/12/21 C1 fell and hit their head which resulted in a red mark on their left side of their head. C1 was sent to the hospital because they were very agitated and staff did not want C1 to further injure themselves with additional falls.

The LPA interviewed C1, however, when asked about the bruising and the falls, C1 responded that they did not know. A review of C1's Individual Placement Plan (IPP) indicates C1 has no safety awareness and requires supervision at all times to prevent injury/harm. An interview with Client 2 (C2) did not yield any pertinent information due to C2 being non-verbal. The LPA was not able to interview Client 3 (C3) due to being admitted to th e hospital or Client 4 (C4) due to them being at their day program. The bruises that C1 had during the LPA's visit on 11/17/21, appeared to be in the end stages of healing to the left and right sides of their head. During today's visit, C1's bruises were no longer visible. The LPA observed a puzzle style floor mat on the floor of C1's bedroom to help mitigate injuries should C1 sustain another fall.

During an interview with C1, C1 stated that they were being properly fed. C1 denied feeling unsafe living in the facility. C1 confirmed that they were happy living in the facility. C1 denied feeling scared of staff. The LPA observed C1 communicating and laughing with staff during the visit. Staff 1 (S1), Staff 2( S2), Staff 3 (S3) and Staff 4 (S4) all denied that C1 is not properly fed. It was reported that C1 has been ill and experienced a decline in their appetite, which may have contributed to their minor weight loss. C1 was admitted to the facility on August 25,2021. On August 26,2021, C1 weighed 145 lbs. On September 27,2021 C1 weighed 151 lbs. On October 25, 2021 C1 weighed 140 lbs. An interview with Client 2 (C2) did not yield any pertinent information due to C2 being non-verbal. The LPA was not able to interview Client 3 (C3) due to being admitted to the hospital or Client 4 (C4) due to them being at their day program. The food menu for November indicates the clients in care are being provided nutritious meals and snacks. The menu also indicates that the menu can be changed based on the clients' choice. C1 raised their shirt and allowed the LPA to see their chest and stomach. C1 is tall and thin, however the LPA determined that C1 did not appear extremely malnourished. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report, 9099C and LIC 811 were provided to April Panaligan.