Complaint Investigation Report

LPA requested and received documented facility daily progress notes at the times of day when clients are loaded and unloaded to and from their Adult Day Program (ADP). There are no documented entries from any staff member concerning the treatment or status of C1 regarding facility loading and unloading procedures. LPA additionally requested and received documented communication between the facility above and the ADP of C1. The documented facility communication with the ADP had no statements from the ADP about any concern over the procedures of loading and unloading by facility staff. All LPA interviews with facility staff, clients, and credible witnesses from outside the facility have no concern over the physical and verbal procedures of facility staff members when loading/unloading clients at any time for any reason. LPA was provided with a recorded video that was allegedly presented by RP as a “hidden camera” recording of the facility staff loading/unloading clients in care. LPA did not observe any inappropriate physical or verbal behavior by staff while loading/unloading clients at the facility. On 08/29/2024 and 09/16/2024 while at the facility, LPA physically observed facility staff unloading clients from their ADP. The procedures used by staff at the facility appeared appropriate as observed by LPA. Through observation by LPA of both the recorded video and onsite in person of staff loading/unloading clients, there was no physical behavior observed by LPA that could be interpreted as forceful pushing of clients.

On 08/26/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding C1 alleging that they sustained a fall on 08/25/2024, resulting in a head injury requiring medical treatment. The UIR noted that on 08/25/2024, at approximately 8:30pm, C1 was returning from the restroom and upon entry to the dining room stopped to pick up food that had fallen to the floor from the dining room table. C1 lost their balance and fell hitting the back of their head on the edge of the wall. Staff immediately assisted C1 and checked them for injuries but did not observe any injuries. Around 10:30pm, the facility changed shifts and the incident was relayed to the nocturnal shift. Staff checked on C1 and noticed blood on C1’s bedroom pillow and found a laceration on the back of C1’s head. Staff immediately took C1 to the Emergency Room (ER) hospital where C1 received three (3) staples to the head wound and was told to follow up with primary care physician. C1 was discharged to the facility the same night. LPA received documented hospital discharge paperwork and facility narrative charting regarding this incident which corroborates the statement of facts presented by the facility in the UIR to the department. LPA interviewed both facility staff and clients in care regarding this incident as a Case Management Visit to the facility above on 08/29/2024. There is no evidence through interviews by LPA or record review conducted by LPA that the injury to C1 on 08/25/2024 was caused by staff roughly handling C1 while loading and/or unloading C1 in the facility transportation vehicle. Continued on 9099-C