Complaint Investigation Report

Allegation: Resident has access to medications resulting in resident overdosing.

On 4/4/23 Licensing Program Analyst (LPA) Shira Stamps conducted an initial complaint visit and interviewed staff and clients. LPA interviewed four (4) staff members. On 4/4/23 at 11:45am, LPA reviewed one (1) out of four (4) client files which include but not limited to the residents IPP(12/15/20), behavior plan(February 2023), written authorization to search 1/02/23 physicians report 7/08/22), On 5/24/23 LPA reviewed the discharge document 3/24/23).

The complainant concern is allegedly Client one (C1) eloped from the facility without a staff member supervision and went into a store and had access to Benadryl. C1 brought the Benadryl into the home, staff did not properly assess C1 before attending the day program as a result C1 overdosed and was hospitalized.

On 3/24/23 while attending Day program, C1 approached staff and told staff that 6 Benadryl were taken the evening before because C1 was unable to sleep. Out of concern C1 was taken to the hospital ER. While in the hospital a significant amount of Benadryl pills was found inside C1’s underwear in a sock. C1 was assessed and based on medical discharge diagnosis 3/24/23, indicates intentional overdose, however it was not terminal.

C1 is intellectually disabled and according to the physician’s report C1 is unable to leave the facility unassisted and requires care and supervision when leaving the home. Review of Behavior plans and IPP indicates that C1 has a history of eloping/stealing and needs care and supervision when leaving the home. While C1 needs supervision when leaving the facility C1 is able to verbally communicate with staff.

Staff interviews indicate that C1 is searched every day and was searched on the day of the incident. Staff indicated they did not keep a log of each search but indicated they did not find medications on C1 that day.

Facility staff indicated C1 goes out in the community at day program, and C1 could have gotten the medications while in day program. Day program staff indicated C1 was also searched that day.

According to client interviews, C1 left the facility out of the back entrance during the evening and walked to a store and stole the Benaldryl and returned home and concealed the medication. Staff never knew C1 left the home.