Complaint Investigation Report

The investigation revealed the following:

Allegations: Staff did not follow client's physician's medication orders and due to staff not following the client’s medication orders, the client had a medical emergency. It is alleged that staff did not assist a client with self-administering their newly prescribed medications and instead continued providing the previous medications, which resulted in the client having a medical emergency. LPA’s interview with one (1) out of four (4) clients revealed that the client is able to express concerns regarding their medications and is able to refuse medication, which they have done in the past. The client reported there is a medication they no longer want to take due to weight gain. The client also stated they have been to the hospital but are unsure whether the visits were related to their medications. Interviews with three (3) staff corroborated that the facility follows written physician orders regarding discontinued or changed medications. An interview with the back-up administrator revealed that one (1) of the four (4) clients had a virtual visit with a physician on 05/21/2026. Following the visit, the back-up administrator was informed by the client’s responsible person that the client’s medications would be changed. The back-up administrator informed the responsible person that any medication changes must be provided in writing for the facility to implement the new orders. That same day the back-up administrator and the responsible person conducted a conference call with AV Mental Health to request a copy of the medication orders. The next day the facility followed up with the pharmacy but they had not received the new medication orders. LPA reviewed the new medication order provided to the facility on 05/28/2026. LPA's review of the client’s MAR revealed the facility documented discontinuation of medication and implantation of new medication. LPA's review of the client's after visit documentation regarding medical emergencies from March and April 2026 indicates that the hospital visits did not result in discontinuation of the medication alleged to have caused the medical emergency.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

No deficiency cited. Exit interview conducted. Due to printer issues LPA emailed report to the facility email.