Complaint Investigation Report

Facility staff not supervising resident that led to injury.

During staff interviews S2 stated the residents and I were in the kitchen when two of the residents had behaviors. S2 stated I observed R1 looking at the peanut butter, so I put it back up on the shelf out of R1s reach and out of site. S2 stated that R1 has a habit of trying to get to the peanut butter and has health issues when he eats peanut butter. S2 stated that R1 has behaviors when he can’t have peanut butter.

S2 stated I did not witness the fall, R2 was agitated so I had him go watch a show in his room. S2 stated R3 needed to change his clothes so I took him in his room to clean up and change his clothes. S2 stated I was helping a resident in the back bedroom when I heard a loud noise, and I heard R1 call out in pain. S2 stated when I arrived to the kitchen R1 was lying on the floor in the kitchen and there was a chair by the pantry door. S2 stated the door was open where I had placed the peanut butter. Staff stated I think R1 had climbed on the chair to get the peanut butter and fell.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.