Complaint Investigation Report

C1’s physician report dated 02/14/2020 revealed C1 is ambulatory and under the category “able to communicate” a note is written reading “non-verbal”. Progress Report dated 08/27/2020 identifies a goal of working on a target behavior of dropping to the floor. The report indicated C1 had 55 episodes of this behavior and noted it was a significant increase from the previous quarter.

Medical records were reviewed and corroborated C1 arrived on 09/26/2020 and was diagnosed with acute lumbar fractures and acute lumbar hematoma. Medical records read a hematoma is a collection of blood trapped outside of a blood vessel. It further reads “It is what we think of as a bruise or a contusion.” Staff interviewed denied abuse or being physically aggressive with clients.

During the course of the investigation a video surfaced of facility staff physically abusing clients. One of the clients was identified as C1. The date of the video could not be identified and therefore could not be tied to this injury or bruising. The Department has taken separate action regarding the video in question.

Regarding the allegation of staff not seeking timely medical attention, it was alleged that staff had reported C1 had been crying on 09/26/2020 before C1 left on outing with non-facility staff. When asked what had been done or could be happening, staff answered they did not know what to do or how to calm C1 down. Interviews with non-staff revealed the names of 2 staff who made this claim. Interviews with both staff did not corroborate the statement.

Based on the interviews conducted and the records reviewed, the investigation did not provide sufficient evidence to substantiate the allegations and as such, the allegations are unsubstantiated.

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.

An exit interview was conducted and a copy of this report, a confidential names list (LIC 811) and appeal rights were provided Licensee/Administrator Manuel Vasquez.