Complaint Investigation Report

On 03/27/2025, the initial complaint investigation was conducted. Documents were obtained to include email correspondence, resident (R1)’s physician’s report, IPP, appraisal/needs and services plan, body check records for March, progress notes, and staff schedule.

On 03/27/2025, 2 staff members were interviewed. Based on interview, the Administrator and S2 states they do body check records every day in the morning and afternoon when the residents come back from school. It was stated that body checks are typically done during daily showers.

The review of facility records shows that on 03/08/2025, the facility noted in their progress notes that R1 returned from school with a bruise on his left and right arm. Based on the body check log the bruise on the left and right arm was first noted on 03/09/2025.

On 03/11/2025, the facility staff noted that R1 accidentally scratched his face. The body check log indicates the scratch on R1’s face in the AM and PM. Staff did not note the bruise from days prior. Staff also did not note any scratches to R1’s fingers and hands.

5 staff members were interviewed. Based on staff interview, the Administrator stated the scratch on R1’s face was reported by staff (S4) who informed the Administrator that R1 scratched his/her face after giving R1 a shower. S4 was interviewed who stated that the scratch on R1's face was because R1 has tendencies to put his hands on his face and ears and scratches it. 5 staff interviewed did not know how R1 sustained the scratches on his/her hands. The Administrator stated that around the time of the incident, R1 was also attending school.

3 out of 5 staff interviewed did not know how R1 sustained the bruise on his/her arms. 1 of the staff (S4) thinks that another resident (R2) was agitated and grabbed R1’s arms, and thinks that is how R1 sustained the bruises on his/her arms. S4 stated to have made a personal note about it in March but did not note the exact date and time.