Complaint Investigation Report

During this hold a fingernail from a staff member made contact with R1 leaving a scratch. Hold was released once R1 displayed signs of tension reduction. Interviews conducted resulted in corroborated statements of appropriate procedures followed, with no intention of injuring R1 during the process of restraint. As result, there is not a preponderance of evidence to prove staff cause an injury to a resident in care intentionally or through inappropriate care and supervision procedures, therefore, this allegation is UNSUBSTANTIATED.

Allegation: Staff restrained a resident in care. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews, it was determined that on or about 8-3-2025, R1 engaged in behavior which led to use of a “high standing hold.” Interviews conducted revealed that this hold was placed on R1 due to R1 attempting to elope in an unsafe manner and a threat to his physical health. Record reviews indicate various interventions including verbal de-escalations, and use of restraints may be used as necessary based on behavior to prevent R1 from harming self and others. Although a restraint was used on R1 by staff, there is no corroborating evidence resulting from this investigation to suggest a violation occurred as a result of using the restraint. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.