Complaint Investigation Report

It was alleged that due to lack of supervision, resident is being assaulted by another resident. The complainant’s concern is that while staff leave the room or go to use the restroom, Resident #1 (R1) is being attacked by Resident #1 (R2). It was reported that R2 pulled a knife on R1, and the police were contacted. Record review of facility’s incident reports revealed that the facility had an incident where R2 called 911, reported having suicidal ideations, and threatened to hurt themselves. Interviews conducted with staff revealed that R2 contacted 911 themselves and claimed to have a knife to hurt themselves. Staff stated that R2 never had a knife in their possession and were not near any other residents at the facility at any time during the incident. Staff also stated that if they need to step away at any time, there are other staff available to watch R2 and the other residents. During an interview conducted with R1, R1 stated that R2 claimed to have had a knife, but they never had one. Additionally, R1 stated that R2 never came to close them or the other residents at the home and added that staff is always around supervising R2 as well as the other residents. Furthermore, during resident interviews, residents stated that they felt safe living at the facility and had no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “due to lack of supervision, resident is being assaulted by another resident”. Therefore, this allegation is being deemed Unsubstantiated at this time.

It was also alleged that staff are not notifying authorized representative of incidents. It was reported that the facility is not notifying the resident’s responsible person when there are incidents that have occurred. Records reviewed revealed that the Administrator is submitting incident reports to the Department within the seven (7) days of occurrence. Records reviewed also revealed that the Administrator is notifying the resident’s responsible person via email which includes a copy of the incident report submitted to the Department. Interviews conducted with the Administrator and facility staff revealed that the Administrator also contacts the resident’s responsible person via telephone call. Staff stated that they document all incidents that occur at the facility and report to the Administrator. The Administrator then notifies all the necessary parties after they have all the information together. Interviews conducted with residents revealed that staff notifies their responsible person and keeps them up to date with what is happening at the facility. Based on records reviewed and interviews conducted with facility staff and residents, the Department does not have sufficient evidence to support the allegation of “staff are not notifying authorized representative of incident”. Therefore, this allegation is being deemed Unsubstantiated at this time.