Complaint Investigation Report

It is documented in R1’s Individual Program Plan (IPP), dated 01/22/2021, as well as multiple other sources, that R1 has a history of disruptive behaviors, including self­injurious behavior, assaultive behavior and not telling the truth.

R1 disclosed to various parties that S1 pushed R1 into a dresser, causing a large bruise to their back/hip area; that S1 pinched their breasts, that staff did not believe them when they reported having seizures and that staff damaged a picture frame that was in R1’s room.

During interviews, R1 stated S1 drug R1 by the hands and on a different occasion, S1 drug R1 by their feet. R1 first stated they lost their balance and fell into the dresser when R1 was alone in their room. Later in the interview R1 said S2 had pushed R1 into the dresser. When interviewed on 03/12/2021, R1 did not disclose any sexual abuse or inappropriate touching. When re­interviewed on 06/01/2021, R1 stated that S1 grabbed R1’s breasts when they were in the hallway. R1 said S1 used one hand and grabbed both her breasts, under R1’s pajamas and that R1 told S3 about the incident the same day.

Staff and all residents were interviewed and denied ever seeing S1 or S2 abuse R1 as alleged. All staff and residents interviewed denied ever seeing or hearing about S1 touching R1 inappropriately.

Staff, S4, stated that S4 once observed R1 lay on the floor of their bedroom, deliberately rubbing their elbows back and forth on the carpet until R1’s elbows bled.

S1 and S2 were interviewed and denied physically abusing R1. There are many notations for R1 inflicting or attempting to inflict injury on others.

Available facility care notes were reviewed. On 11/30/2020, it is noted that staff asked R1 to take a phone call in their room, when staff heard R1 talking to their mom about wanting to move because "staff S1 drug her across the floor." R1 stated, "Ok, I won't lie anymore," and continued with the phone call in the living room and did not take the call to their bedroom.

Administrator S3 stated on 03/09/2021 (two days prior to the bruise being observed in the hospital), she saw R1 fall into her empty dresser, while standing in R1’s bedroom doorway. Documented care notes were reviewed and were consistent with S3’s statements.