Complaint Investigation Report

To ensure C1’s safety, a staff member attempted to follow C1 but lost track of them. Approximately, five minutes after C1 had left the facility, the staff received a phone call from a nearby medical office to let them know C1 was with them. When staff arrived at the medical office, they observed C1 was being escorted inside. An employee from the medical office informed facility staff that they had called local law enforcement. Subsequently, law enforcement called an ambulance to transport C1 to a hospital for examination. C1 reported to law enforcement that their arm hurt because facility staff had physically hit them on their arm. However, a few minutes later, C1 changed their statement indicating they had hurt their arm when they fell down the stairs at the facility.

During an interview, C1 maintained they had hurt their arm when they fell down the stairs but could not recall the date that it happened. C1 was observed with no visible signs of abuse or injuries. C1's chest, face and arms were observed free from any signs of bruising. During the interview, C1 also denied staff hurting them physically or verbally. Review of facility records indicated facility staff reported the elopement incident to C1's Responsible Party, Community Care Licensing and the client’s placement agency as required by Title 22 regulations.

Review of C1’s records including the Appraisal/Needs and Services Plan (LIC625), Consumer Placement Referral Report, Physician’s Report, and other facility records relevant to the investigation indicated C1 had a diagnosis is Mild Intellectual Disability. C1 tended to engage in inappropriate behaviors including multiple elopement attempts, verbal and physical aggression, and self-injurious behaviors. C1 had a documented history of continually contacting 911 to go to the hospital for non-emergency situations.

Interviews with staff and outside sources confirmed that C1 had a history of elopement and calling 911 to be taken to the hospital for no apparent medical need. Records review and interviews with outside sources indicated that C1showed the same pattern of behavior when they were placed in other adult residential facilities. Interviews with outside sources indicated that they never observed staff physically or verbally abusing C1. Facility staff denied the allegation.

Based on interviews with staff and outside sources, and review of pertinent client records and facility records there was insufficient evidence found to support the allegation that facility staff physically abused C1. (Continue on LIC9099C