Complaint Investigation Report

Three out of three staff interviewed stated there was no valid doctor’s order on file authorizing the facility to administer Zepbound at that time. Staff reported that the prescription was obtained by C1’s responsible party from a neurologist unfamiliar with the facility and was filled through an outside pharmacy not used by the facility. Staff stated they cannot administer any medication without a valid physician’s order, in accordance with Title 22 regulations.

Staff also reported that C1’s responsible party has previously provided medications to C1 without notifying the facility. Staff indicated that C1 does not have the ability to safely self-administer injections, and the facility is not authorized to administer injectable medications without proper orders. Staff further stated that they have followed all regulatory requirements despite challenges communicating with C1’s responsible party.

LPA interviewed a witness involved in discussions between the facility, responsible party, and day program. The witness confirmed that the facility could not administer the medication without proper physician orders and questioned whether the responsible party had legal authority to make such decisions.

LPA interviewed C1, who stated they do not like receiving the injections and do not understand why they are being given. C1 reported feeling uncomfortable with their responsible party and stated they feel pressured to take the injections. C1 also stated that the facility provides their medications correctly and reported no concerns with the facility’s medication management. C1 expressed that they are satisfied living at the facility.

LPA reviewed C1’s Medication Administration Record (MAR), which showed medications are being properly documented and administered as prescribed. Discontinued medications were appropriately noted.

Record review also showed that on January 6, 2026, C1’s psychiatrist issued an order to hold the Zepbound medication due to side effects, including drowsiness and falling asleep at the day program. On February 4, 2026, a physician authorized resuming Zepbound, with approval from the psychiatrist, along with adjustments to C1’s medication schedule. Staff have since followed these updated orders, and improvements were noted in C1’s alertness at the day program.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that staff are not dispensing medications as prescribed. Evidence shows the facility followed physician orders and regulatory requirements regarding medication administration.

(Complaint investigation continued on LIC9099C)