Complaint Investigation Report

that R1 was admitted on 4/12/26 for drug overdose. R1 was given Supratherapeutic Lorazepam at 2 mg instead of 0.5 mg PRN and Clozapine 25 mg which was no longer prescribed with multiple dose over 1-2 days leading to progressive sedation. Staff acknowledged responsibility for the medication error, and the staff member involved was subsequently terminated; therefore, no further interviews were conducted. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time.

Exit interview conducted/copy of report given