Complaint Investigation Report

The investigation revealed the following: Regarding allegation: Client is being over medicated. It is alleged C1 was paranoid, slurred speech, mentally impaired, weight loss, and drowsy from being over medicated on 10/1/22. Interviews conducted with staff who provide medication revealed, staff follow physician’s orders to provide medication to clients, once the medication is discontinued or change medication gets properly destroy and noted on medication sheets. Documents reviewed for C1 revealed the following, medication sheets revealed C1 was on 11 to 13 medications in the months of August through October 2022. Facility recorded changes in three medications due to increase or decrease of dosage between August and September 2022. The changes were noted and adjusted by the psychiatrist providing care at the time, who provided care at least every two weeks. Per clinical review conducted the following was concluded: There are no hospital blood lab results to indicate results of levels of medication on C1’s system for the visits on 9/3/23 or 10/2/23. The medication was adjusted by the physician, and the staff are not capable of adjusting medication. Per medication review there was no medication errors or medication missing to assumed that the facility had dispense over medication to C1 between August to October of 2022.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Staff did not observe changes in client's condition and Staff did not seek medical attention for client. It is alleged that on 10/1/22 C1 could not eat or sleep and had dry heaves all night. On 10/2/2022 responsible party(RP) took C1 to the emergency room (ER), and “the doctor said, it was good responsible party took C1 to the ER, as C1 had acute Pancreatitis.” Document review revealed the following: Incident reports note: On 9/3/22 C1 was send to the hospital via 911 due to client not being able to get up from the floor after paramedics’ evaluation. C1 was discharge back to the facility on 9/7/23 with no changes on care. Needs and Care Plan updated on 5/26/22 note mental health changes and goals. However, it does not note any physical health needs or changes. Physician’s orders and consent of medication adjustment sheets were observed from 8/31/22 to 9/27/23 for C1, which track psychiatrist medical care. On 10/1/22 C1’s RP picked C1 up and took C1 for an overnight visit. On 10/2/22 C1’s RP took C1 to the hospital due to observations and health concerns. Medical records review note the following: Hospital intake review for 9/3/22 does not note any treatment or symptoms for pancreatitis issues or other major concerns. C1's hospital intake notes dated 10/2/22, note C1’s intake was due to lack of intake of food and liquids.Based on clinical review conducted, (CONTINUED ON LIC 9099C)