Complaint Investigation Report

During the investigation, interviews with staff were conducted. Staff members indicated that the two clients involved in the altercation “sometimes disagree and it can get heated.” At the time of the fight, it was discovered one (1) staff member was present in the facility for three (3) clients. Staff admitted that nobody went outside with the two fighting clients as they could not leave the remaining resident in the facility alone. Staff claimed they observed the altercation from inside the facility to make sure the clients did not get hurt. Staff further admitted clients have been outside the facility yelling or causing general disturbances in the neighborhood. Staff members stated sometimes clients need to “take a breather” and they are allowed to take a walk and deal with their frustrations on their own. Staff claimed they will attempt to redirect clients when these moments happen.

Witness interviews were also conducted. Multiple witnesses stated there have been several instances where clients have been outside the facility without supervision yelling profanities and causing disturbances. Witnesses indicated they did not feel safe and were also concerned for the safety of the residents without any direct supervision during what appeared to be behavioral outbursts. During record review, LPA noted two (2) of three (3) residents are medically cleared to leave the facility without staff supervision. Both clients involved in the altercation observed in the video footage were confirmed to be able to leave the facility unassisted.

Based on observation, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC 9099-D. Exit interview conducted and a copy of this report was provided to Crystal Monismith, Administrator, via email.