Complaint Investigation Report

Regarding the allegation: Staff dispensed medication that was not prescribed to the client. It was alleged that S2 had given C1 medication that was not prescribed. To investigate the allegation, LPA attempted interviews with four (4) clients and fourteen (14) staff members. LPA attempted to interview C1-C3 but due to their various medical diagnosis, they could not be interviewed. LPA terminated the interviews. LPA attempted to interview C4, but they were not present during LPA’s initial visit. LPA’s interview with seven (7) of the fourteen (14) staff members stated they have not witnessed any staff members to give C1 or any other client’s medication that is not prescribed to them. LPA attempted to interview S2 but S2 is currently on a leave of absence and could not be contacted. LPA attempted to contact S12-S14 but was unsuccessful.

During LPA’s physical plant tour, LPA observed the medication to be kept locked in a kitchen cabinet. LPA observed all client’s medication to be kept stored in their own individualized containers labeled with their corresponding information. LPA observed C1’s Medication Administration Records (MARS) to not contain the said medication per the Reporting Party (RP).

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff are in violation of client’s personal rights. It was alleged that staff have violated C1’s personal rights such as but not limited to: being disrespectful, mocking and reframing from allowing C1 to receive telephone calls. To investigate the allegation, LPA attempted interviews with four (4) clients and ten (10) staff members. LPA’s interview with all staff members revealed that they have not, nor witnessed staff members violating C1’s personal rights. When questioned regarding the alleged photo that was displayed to offend C1, nine (9) of the ten (10) staff members denied ever witnessing such photo. LPA’s interview with an additional Co-Reporting Party claimed to have seen the photo in question but did not witness who may have placed said photo.

LPA’s interview with S1 revealed that C1 has various behavioral tendencies that can lead to other medical episodes. Due to these episodes, S1 has informed C1’s Case Worker from North Los Angeles Regional Center (NLARC) of such incidents and how staff have responded to help defuse the situations for the health and safety of C1. LPA’s interview with C1’s Consumer Service Coordinator (CSC) confirmed that they have been made aware of such situations resulting in C1’s Individual Program Plan (IPP) to be updated reflecting such incidents. LPAs record review of C1’s IPP confirmed such exhibited behaviors due to isolated incidents involving C1 notated. (continue to LIC 9099-C)