Complaint Investigation Report

Interview with S1 revealed they observed increased agitation in R1 and reported it to R1’s physician and a nurse practitioner from the physician’s office about medication changes. A nurse who worked with R1’s physician reported the suggested medication change of prescribing Seroquel to R1’s conservator, and the conservator denied the medication change. Interview with R1’s conservator at 3:00 p.m. on 07/10/25 confirmed that R1 was never prescribed Seroquel and never took Seroquel. R1’s conservator also confirmed that the suggested medication change was reported to them by the physician’s assistant. Record review of R1’s medication list confirmed no orders for Seroquel were ever prescribed. Record review of facility emails revealed the executive director informed R1’s conservator that S1 reported R1’s increased aggressive behaviors directly to R1’s physician and nurse practitioner prior to scheduling a care plan meeting with R1’s conservator. Interview with the executive director confirmed these details and further confirmed that R1 was never prescribed Seroquel or assisted in taking Seroquel per the orders of R1’s conservator. Based on interviews and record review, staff reported a behavioral change in R1 and suggested a medication change. R1’s conservator was notified of the potential change, and R1’s conservator denied the medication change, so R1 was never prescribed new medication. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Copy of report provided.