Complaint Investigation Report

C1 had been living at the facility since December 12, 2014, and was diagnosed with moderate Intellectual Disability, Autistic, Epilepsy and Drop Seizure Disorder, (causes sudden loss of muscle strength which often results in unexpected falls) and Posterior Inferior Cerebellar Artery (PICA), (eating disorder in which people compulsively eat one or more nonfood items such as clay, paper, or dirt). According to medical records C1 was a fall risk and had a doctor’s order and documented exception approved by the Department to use a protective helmet to minimize serious head injuries. Although C1 ambulated using a wheelchair and was assessed as non-ambulatory, C1 was able to walk around the facility. Despite staff’s close supervision and efforts to ensure C1 always wore their helmet, C1 was known to remove their helmet and roam around the facility at night. In addition, to prevent serious injuries from a fall, the facility added a rubber mat on the floor by C1’s bed and an alarm mat at night when C1 was sleeping. The mat would set off an audible noise in the staff’s rooms to alert staff when the mat was stepped on. If staff became aware of C1 wandering at night they would guide them back to their room, but otherwise C1 would return to bed on their own.

On December 8, 2021, during incontinence care, staff noticed C1 had slight bruising and swelling to his right arm. Per staff interview statements, the source of the injury was not known. C1 was nonverbal and was not able to explain how the injury occurred. In addition, C1 was known to have a high pain tolerance which made it difficult for staff to know if the client was experiencing pain or discomfort. Although C1 was not showing any signs of pain or discomfort, staff activated 911 and C1 was transported to the hospital by emergency paramedics personnel. Hospital personnel notified facility staff that C1 had sustained a fractured arm.

Staff reported that C1 was sharing a room with another Client (C2), [an LIC 811 Confidential Names List was provided to staff to identify the Client]. C2 was nonverbal and was diagnosed with Intellectual Disability, Autism Spectrum Disorder, (a neurological and developmental disorder that affects how people interact and communicate with others). During interviews, staff consistently indicated that C2 was observed twice standing at night by C1’s bed on or about the date C1’s injury was discovered. C2 was known not to like loud noises and C1 used to grind their teeth. Staff were unsure if the combination of the two roommates’ may have resulted in inadvertent client-on-client injury. Subsequently, staff relocated C1 to a different room to minimize future risk. Staff interview statements noted that another possible explanation for C1’s injury was a result of an unwitnessed fall caused by a drop seizure. Based on the information available at the time, it was not possible to determine the source of the client’s injury.