Complaint Investigation Report

According to C1’s Face Sheet and latest LIC625 Appraisal/Needs and Services Plan, they had a case management agency acting as their authorized representative for health matters. C1’s medication-prescribing physician (PCP) was also employed through C1’s case management agency. According to C1’s latest LIC602 Physician’s Report, C1’s doctor diagnosed them with Schizophrenia and Depression but also wrote that they were not confused, able to follow instructions, and able to communicate. However, C1’s doctor determined that C1 required staff assistance to safely store and take their medications.

Records and interviews, corroborated by LPA observation, aligned to show: On 12/04/2024, C1’s pharmacy delivered refills to the facility for most of C1’s prescribed medications, except for four (4) of them. Of these four (4), two (2) were not refilled because they had been discontinued by PCP. However, the other two (2) medications [i.e., “Medication A” and “Medication B”] still had active orders/prescriptions and said refills were needed by C1. Per C1’s official medication list, “Medication A” was to be taken once per day in the morning before noon, and “Medication B” was to be taken once per day at bedtime. C1’s pharmacy on 12/04/2024 provided written notice to Licensee’s staff that Medication A and Medication B were not refilled due to awaiting needed authorization from PCP. Then on 12/11/2024, C1 took their last doses of Medication A and Medication B. Licensee’s staff did not independently contact/alert either PCP or RP leading up to C1 running out of medication, or initially after C1 had run out of those medications.

During an unrelated visit on 12/12/2024, outside case management personnel recognized that C1 had run out of Medication A. They alerted PCP, who coordinated with C1’s pharmacy for the refill of Medication A to be delivered that same afternoon. Licensee’s staff resumed giving C1 their Medication A starting 12/13/2024 (the next morning after refill receipt). As a result of the above, C1 missed one (1) morning dose of their Medication A on 12/12/2024.