Complaint Investigation Report

Concern was that R1 would fall on R1’s face and cause injury. LPA was allowed to review a video showing that R1, while seated in the wheelchair tried to get out of the wheelchair multiple times. In the video R1 was seen scooting while in the wheelchair, R1 swung arms wide, bent fully at the waist and was reaching around their legs and wheels for no clear reason. R1 was not verbal in the video, and did not express any verbal requests, just constant movement and trying to grab at items around them and various attempts to get out of the chair. Interviews and record review confirmed R1 is not able to self-release their wheelchair seat belt.

Interview on 6/5/25 at 4:46 p.m. with nurse practitioner stated they know R1 to be aggressive, can hit, and has extreme behaviors, but at this time, they do not believe an order was approved to allow for seat belts as R1 was placed into care at the facility while practitioner was unavailable.

Based on LPAs observations, interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.