Complaint Investigation Report

Client sustained unexplained injuries while in care – UNSUBSTANTIATED

It was alleged that the client sustained unexplained injuries while in care. It was reported that the client had a large silver dollar size abrasion on their forehead and a red abrasion on their nose.

The licensee stated that the client did have an abrasion on their forehead with no discoloration. Licensee stated they thought that the client could have hit their head on the headboard of the client’s bed. Licensee stated that the client would sometimes place their head in the cubby holes of the headboard.

On 11/03/2021 during LPA’s tour of the facility, LPA inspected the client’s bedroom and observed a wooden headboard with “cubby holes” in it. The licensee has since removed the headboard with cubby holes from the client’s bedroom in order to reduce the risk of injury.

During staff interviews it was learned that staff either saw a mark on the client’s forehead or heard that the client had a mark on their forehead. 3 staff stated that the client may have hit their head on the headboard of their bed. 3 staff stated that the headboard has been removed from the client’s room.

On 12/30/2021 LPA Knight toured the facility and confirmed that the headboard had been removed from the client's bedroom.

During client interviews 2 of 3 clients stated they were not aware of any client in the home with any injuries. 1 client is non-verbal and was not able to be interviewed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.

An exit interview was conducted. A copy of the report was emailed to facility licensee /administrator David Bortz. No deficiencies were cited on today’s date.