Complaint Investigation Report

During the interview process, day program and facility staff were interviewed. It was determined that a facility staff, admitted to observing the bruising while showering R1 on 07/03/2023 but did not report the bruising to anyone. Day program and facility staff all consistently provided statements that the bruising and swelling resolved within a few days.

The second incident of bruising occurred on 07/10/2023. A second staff stated that he toileted R1 on 07/10/2023 at about 1400 hours and when R1 stood up, R1 had bruising on his penis. The staff person attested that there was no bruising prior to R1 sitting down and that R1 had been sat down in a way that ensured R1 penis was not constricted. Staff suspected that R1 scooted himself forward while he was sitting on the toilet. R1 was taken to the ED, as well as his primary care provider, who was interviewed and stated that she had never had cause for concern regarding R1 care and that the explanation R1 caregivers provided had been plausible for the cause of R1’s injury.

Multiple staff were interviewed and provided consistent statements that R1 had a propensity to “plop” down and scoot himself on the toilet seat while toileting. Facility administrators promptly sought medical treatment following both injuries and installed a different style toilet seat after witnessing the second injury occur while R1 was toileting. All staff stated there have been no further injuries or issues since the toilet seat was changed.

This agency has investigated the complaint alleging Neglect/Lack of Care and Supervision resulting in an injury. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to Program Manager Angel Doss.