Complaint Investigation Report

C1 later told staff that they did not like C2, wanted them to move out of the facility, and were trying to retaliate against them for making up the claim. Staff additionally informed that no other clients observed the interaction and facility camera footage did not show C2 entering C1's room the day in question. Staff informed that due to behavior and cognition, both C1 and C2 had historical patterns of making statements and accusations that were not true.

C1 was interviewed during an unannounced facility visit. C1 provided inconsistent information than what they had originally informed regarding the accusation. C1 informed that they consented to interactions with C2 and that they had not been threatened by C2. An attempt was made to interview C2, however C2 declined to be interviewed.

An outside source (OS1) from a placement agency familiar with both clients was interviewed. OS1 was aware of the accusation and had conducted interviews. C2 denied having any physical contact with C1. C1 wanted C2 to move out of the home and was upset that C2 had returned after hospitalization. OS1 informed that the clients both consented to spending time together in C1's room and that they had privacy rights which allowed the door to be closed with 15-minute status checks by staff. While OS1 did not know what occurred while the clients were in the room together, OS1 noted that the clients both had historical patterns of making up situations.

The facility submitted a Special Incident Report dated 10/21/2024 and a Report of Suspected Dependent Adult/Elder Abuse dated 10/21/2024. The reports were consistent with staff, client, and outside source accounts of the event, with the exception of C1's recant during interview that they had been threatened and did not consent to interactions with C2. The abuse report informed that C1 had been, "…stating for days how [C1] dislike[d] this peer and that [C1] wanted to get [C2] in trouble." The report went on to state that video footage showed C2 did not enter C1's room the night of accusation, and that all clients had keypad locks on their doors with no client knowing another client's door code. No records were found to corroborate the allegation.

The investigation produced clarifying information that C1's report of being inappropriately touched by C2 was not from direct witness, but from C2 telling C1 that the event occurred.