Complaint Investigation Report

LPA interviewed four (4) staff, and all four (4) staff admitted that PM medication was administered to C1 in the AM which is not physicians order. One staff member was on vacation and LPA was not able to interview staff. (continued on 9099C)

LPA interviewed two (2) clients and one client stated all medications are administered as ordered. C1 did not recall the incident. Three (3) clients were not able to answer questions due to cognitive impairment. LPA reviewed Regional Center Corrective Action Plan (CAP) and MAR and both show that the facility did not follow Physician's orders on 09/24/2024. Facility called 911 and C1 was transported to emergency room and returned to facility the same day. There is sufficient evidence to substantiate this allegation.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated.

Deficiencies are cited on the attached LIC9099D.

Exit interview held. A copy of the report, 9099D and appeal rights were provided.