Complaint Investigation Report

During an interview with Client 2 (C2), C2 recalled C1 liking to stand up and sit down often. C2 witnessed C1 fall “a couple of times” but did not witness the December 2, 2019, incident. An Interview was conducted with Client 3 (C3) and it was revealed that C1 and C3 lived at the same group home in the past. C3 said that C1 would often stand up and fall at the group home. The Department attempted an interview with C1 but due to the client’s cognitive impairment, C1 was not deemed a credible witness.

A review of unusual incident reports obtained in the facility file do not show any incidents involving C1 except for one dated 12/2/15 involving C1 possibly having a seizure and emergency services were immediately called.

A review of the client's Individual Program Plan (IPP) indicates that C1 requires staff to be around when walking due to C1’s unsteady gait, compromised vision and dementia which could result in falls. C1’s Physician’s Report indicates a primary diagnosis of dementia and a secondary diagnosis of intellectual disability. A review of records revealed C1 sustained multiple facial fractures as a result of the fall in question.

Interview with outside source agency (OSA) confirmed that C1 is ambulatory to some extent but requires one on one assistance when walking with a walker also C1 can be non-compliant. OSA stated they have never had an issue with Innovative Center and felt that they were doing a great job.

Due to the client’s propensity to stand up without warning and non-compliant nature, it could not reasonably be attributed to the lack of supervision that C1 fell and sustained injuries.

Based on interviews and review of documentation, the findings were established to be unsubstantiated. This finding means although the allegation may have happened or could be valid, there is not a preponderance of evidence to prove that the violation occurred. An exit interview was conducted with Assistant Administrator Cynthia Sison to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided via E-mail.