Complaint Investigation Report

Based on staff interviews, Administrator (ADM) stated that on 08/29/22, ADM received a phone call from C1's RP to inform that C1 will not be attending the day program because C1's medication was not administered as a result C1 had seizure evening of 08/28/22. Administrator stated was not aware nor there was a report received that C1's medication bottle was not received nor it was not administered on 08/28/22 by the staff responsible or designated to assist C1 with medication.

Administrator conducted an in-house investigation with Staff (S1), C1's RP informed S1 of C1's medication in the bag during R1's dropped off on 08/28/2022. S1 subsequently informed another staff (S2) then S2 informed S3 about C1's medication. Furthermore, aside from the 3 staff (S1-S3), staff (S4) who checked C1's bag for lunch apparently saw C1's medication bottle but did not verify if medication was given either.

Based on staff interviews, Administrator (ADM) was informed that C1 was observed alone in a room unsupervised on 08/28/2022 by R1's RP. RP also stated that C1 was wearing a seat belt.

ADM stated an in-house investigation was conducted with staff who were involved. ADM stated staff assigned to disinfect the facility had decided to bring C1 in a room (designated as their sick room located across the facility kitchen) to prevent C1 from inhaling toxins produced by cleaning disinfectants during an end of the day facility sanitation. ADM stated that C1 was the only client left in the facility while waiting to be picked up by RP. ADM stated that staff (S4) was the designated staff to supervise C1 in the room. S4 left C1 for less than a minute for the office. S4 did not have a line-of-sight supervision of C1 from the office.

ADM stated that on 08/28/2022, staff brought clients including C1 for a walk. ADM stated that C1 did not have a steady gait, exhibits behaviors such as grabbing staff and clients, and being disruptive. Staff has decided to utilize wheelchair with a seat belt to prevent C1 from falling. ADM stated there was not a medical note for the use of seat belt.

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