Complaint Investigation Report

Based on staff interview, the (2) staff who were part of the incident both admitted that on 10/29/2024, they left the side doors of the van open while they were dropping off other clients at a different location, when C1 fell out of the van. 2 out of 2 staff admitted that the side doors of the van should have not been left open. Based on staff interview, it was stated that the (2) staff members “cut corners” and violated several day program policies including not tying R1’s wheelchair down. On 11/06/2024, 2 out of 2 staff were terminated.

Based on review of C1’s medical records, C1 suffered fractures to his/her arm after falling out of the day program’s transportation van.

It was also alleged that staff did not seek timely medical attention for C1, after C1 fell out of the day program’s transportation van. It was alleged that the day program staff did not call 911 and instead, put C1 back in the van and drove C1 home.

It was stated that when C1 arrived home, C1 was crying and had bruising, a scrape on his/her forehead and hands were bleeding.

Based on staff interview, when C1 fell out of the van the 2 staff members picked up C1 where they observed C1 had a scratch on his/her forehead and elbow. Staff transported C1 to his/her home, which according to Google is 0.4 miles away and a two-minute drive from where the incident occurred.

According to the Program Director (PD), 2 out of 2 staff told the PD that C1 had a scratch on his/her arm but did not mention anything about C1 sustaining a scratch on his/her head. The PD did not instruct staff to take C1 to the hospital as 2 out of 2 staff only reported a minor injury which was a scratch on C1’s arm. The PD stated that if his/she had known C1 sustained a head injury, the PD would have instructed staff to call 911.

When C1 arrived at home, C1’s care staff called 911 where it was found that C1 suffered fractures to his/her arm after falling out of the day program’s transportation van.