Complaint Investigation Report

The LIC 602 noted C1 was ambulatory, was able to ambulate without assistance, was able to care for own toileting needs, and able to leave the facility unassisted. Motor impairment was noted for C1, as history of Extrapyramidal Symptoms.

Interviews with internal and external sources confirmed C1 was able to ambulate without assistance, did not require the use of Assistive Ambulatory Device (ADDs), but did display stiff lower extremities. During the time in question, the bathroom primarily used by C1 was under renovation. Staff maintained the bathroom closed when renovations were not occurring, and clients were redirected to use a different bathroom. This additional bathroom was in a different client’s bedroom, Client # 2 (C2). Review of the Incident report submitted by the facility, along with interviews, confirmed C1 fell in C2’s bedroom, and it was believed C1 had tripped on cords, or a rug.

Interviews revealed C2 had television and other cords laying in front of the entrance to the bathroom. Staff confirmed management was notified of this hazard. Staff and management had repositioned the cords, encouraged C2 not to place the cords in front of the doorway, but C2 would sometimes place the cords in front of the bathroom door. A telephone interview was attempted with C1, but C1 was not able to recall ever residing at this facility. C2 recalled C1, but did not recall C1 falling in C2’s bedroom.

Based on the evidence obtained during the investigation, the allegation was unsubstantiated.

An exit interview was conducted with Staff Jamie Duey-Toscano. A copy of this report, LIC 811 Confidential names list, and Licensee/Appeals Rights (LIC 9058), were provided to Administrator Roman Price.