DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Summary of Investigation
PRIVATE ICF/IID PROVIDER

Case Number: E1312019A Waiver: Private ICF/IID DIDD Investigator: James White

Agency Responsible: Orange Grove Center

Date: December 19, 2013

I. Initial Allegation(s):

It was reported that the person served had left knee replacement surgery on
11/4/13. She was reportedly doing well post-operation. On 11/30/13, an accident
report was completed indicating that the person served "bumped her knee in the
bathroom". There was some oozing from the surgical site. The surgeon was
notified and advised the agency to use steri-strips on the area. The person
served went to see the surgeon on 12/2/13 and the doctor did not make changes
to her care. On 12/5/13, the person served returned to the surgeon's office and
saw a different doctor. This doctor stated that the person served had a ruptured
tendon. The person served was scheduled for emergency surgery on 12/7/13; at
which time, her left patella was removed (due to significant damage) and tendons
were repaired. The person served remains hospitalized at Park Ridge Hospital in
Chattanooga. It is unknown if the bump described in the accident report on
11/30/13 caused the extensive damage to the knee. An investigation of this
serious injury of unknown cause will be completed.

II. Conclusion(s):

A preponderance of evidence does not exist to support the allegation that any of
the person serveds staff caused or contributed to the serious injury of unknown
cause by being abusive or neglectful. This case is not substantiated for abuse or
neglect.

The conclusion(s) is supported by the authority of the DIDD Provider

Manual, Chapter 18, 18.3.A.2, for Community Providers and/or Private
ICF/IID.

III. Recommendation(s) For Community Providers and Private ICFs/IID:

A. For substantiated investigations, the Provider or Private ICFs/IID should

develop a response and plan of correction.
1. As relevant to the incident investigated, a plan of correction shall address
the following:
a. What has been done to safeguard the person;
b. What procedures, if any, have been developed and implemented for
protecting people from further abuse, neglect and/or exploitation; and

CONFIDENTIAL The information contained herein is the property of the Tennessee Department
of Intellectual and Developmental Disabilities and is not to be disseminated or duplicated.
1
 c. If the incident was reported to DIDD in an untimely manner (as
identified in this final investigation report, section IV.B.), what has been
done to address late reporting.
2. The Provider or Private ICFs/IID response to substantiated investigations
shall consist of:
a. The Plan of Correction;
b. Verification of any staff disciplinary actions; and
c. Verification that the alleged staff person(s) was notified of the outcome
of the investigation.
3. It is recommended that the Provider or Private ICFs/IID email the response
and plan of correction to DIDDINVPOC.East@tn.gov within fourteen (14)
calendar days from the release of this report. The release date is the day
the Office of Investigations forwarded the report to the Provider via email.
B. For unsubstantiated investigations, it is recommended that the Provider or
Private ICFs/IID develop a response (do not submit to DIDD) to include:
1. Verification that the alleged staff person(s) was notified of the outcome of
the investigation;

2. If the incident was reported to DIDD in an untimely manner (as identified in

this final investigation report, section IV.B.), what has been done to
address late reporting; and
3. Verification that all incidental information was addressed.
IV. Recommendation(s) for DIDD ICFs/IID Facilities:

A. The Administrator shall review the investigation report and will develop a
written corrective action plan. The plan shall be submitted to the regional
office, the Deputy Commissioner of Operations, and the Commissioner within
fourteen (14) calendar days of receipt of the report.
B. The corrective action plan shall address the information contained in the
report and shall also include the following:
1. Corrective and preventative actions that have or will be implemented,
including any disciplinary actions;
2. The timeframe or target date for full implementation of the corrective and
preventative actions;
3. Description of individualized supports that have been provided or offered
to assist the person supported in coping with the event;
4. A response to any incidental information noted by the investigator.
C. It is recommended that the Administrator email the corrective action plan to
DIDDINVPOC.East@tn.gov within fourteen (14) calendar days from the
release of this report. The release date is the day the Office of Investigations
forwarded the report to the Provider via email.

CONFIDENTIAL The information contained herein is the property of the Tennessee Department
of Intellectual and Developmental Disabilities and is not to be disseminated or duplicated.
2
 V. Incidental Information:

During the course of this investigation it was noted:

The person served has excellent therapist and support staff who are
providing assistance during her surgical recovery.

Per the DIDD Provider Manual, Chapter 18, 18.4.D.4, for Community Providers
and Private ICFs/IID or the Protection from Harm ICFs/IID Policy 100.1.1.VI.K.8 for
DIDD ICFs/IID Facilities, the summary of this investigation should be discussed with the
involved persons served within fifteen (15) business days of the receipt of the report. If
a legal representative has been appointed, they should be invited to participate in this
discussion. The space below has been provided for your convenience as a means by
which for you to document the fulfillment of this requirement.

Person Served or Legal Representative:

Signature Date & Time

Printed Name

Witness:

Signature Date & Time

Printed Name

CONFIDENTIAL The information contained herein is the property of the Tennessee Department
of Intellectual and Developmental Disabilities and is not to be disseminated or duplicated.
3