Complaint Investigation Report

On 11/05/20 and 11/20/20 Client 1 had violent outbursts leading to police involvement. Client 1 was hospitalized for self-inflicting injury due to the outbursts. Facility staff repeatedly communicated their concerns to Client 1’s medical and mental health providers in order to assist in addressing Client 1’s aggression and self-inflicting injuries to themselves and violence toward others. Staff reported that they attempted to block Client 1 from hurting themselves but denied restraining or causing injury to Client 1. During their interview, Client 1 admitted to having no control over their own violent behavior.

After reviews of clinical documentation, police reports and interviews of staff, clients, outside sources and Client 1 there is insufficient information to support the allegation that lack of supervision resulted in Client 1 sustaining injury and hospitalization.

Based on the evidence obtained during this investigation, the allegation that lack of supervision resulted in a client sustaining injury and hospitalization is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator Brown; a copy of this report and Licensee's Rights (LIC9058) were provided to Administrator Brown.