Complaint Investigation Report

Review of C1’s seizure record revealed that C1 had 38 seizures between July and August 2020 and C1 had multiple seizures on the same day, but those records did not provide any information regarding any injuries that C1 may have sustained as a result of the seizure.

Interviews and review of medical records for C1 revealed that in September 2020, C1 was seen at the hospital for an evaluation after a seizure that occurred in the bathroom. Evaluation of C1 by hospital staff revealed that C1 sustained a face laceration and that C1 also had bruising to the inner thighs. Interviews with C1 and facility staff did not reveal any indication of the cause of the bruising on C1’s thighs. Interviews with staff revealed that staff did not conduct thorough body checks of clients, including C1, during showers or during assessments for injuries. C1 denied any inappropriate physical or verbal interactions or rough treatment by facility staff. Facility staff denied any inappropriate physical or verbal interactions or rough treatment of clients, including C1.

C1 stated that both male and female staff assisted C1 with bathing, however, interviews with staff revealed that only female staff assisted female clients with showering. Interviews with staff revealed that staff would assist C1 to set up prior to a shower and would leave C1 alone in the bathroom to shower. Assessment and care records and interviews with staff and clients revealed that C1 showered independently while using a shower chair and staff were instructed to check on C1 periodically by asking C1 if they needed any assistance through the door. Interviews with staff and clients and review of incident reports submitted to the Department in 2020 revealed that C1’s seizures would occur without warning and that C1 had fallen in the bathroom during a seizure in the past. Interviews with staff revealed that C1 would sustain injuries due to falling or hitting objects during seizures and in the past, hospital staff had voiced concerns to facility staff regarding bruising and marks that C1 sustained. Interviews revealed that staff were not always able to prevent C1 from falling during a seizure. When C1 had a seizure while in the bathroom, C1 was able to call for staff through the door and request assistance. Interviews with staff revealed that C1 was considered a fall risk and in response, the facility staff had installed floor padding to C1’s room, installed grab bars in facility bathrooms, and C1 used a padded helmet to prevent head injuries.