Complaint Investigation Report

Records and interviews showed: C1 was diagnosed with Schizophrenia and relied on assistance from facility staff to store and take their prescribed medications. C1 had three (3) prescription medications [i.e., Medication A, Medication B, and Medication C] that they were supposed to take in the evening/bedtime, every day. During the evening of 01/15/2025, Staff #1 (S1) had sole responsibility for handing the clients' their medicine pills/tablets. Due to themselves being confused, S1 did not give C1 their three (3) prescribed evening/bedtime medications on that date. S1’s error did not affect the other clients in care on that date. CCLD also did not find evidence of C1 not receiving their medications on other dates.

According to C1’s medication list and supplemented by academic review: Medication A was an antipsychotic drug prescribed to treat C1’s Schizophrenia. Medication B was an antispasmodic drug prescribed to mitigate side effects of Medication A, which were related to C1’s muscle control and normal movements of the body. Medication C was prescribed to treat C1’s tachycardia (i.e., a condition where the heart beats abnormally fast). Per interview of C1 themselves: After missing their evening/bedtime doses of Medications A, B, and C on 01/15/2025, they experienced increased anxiety, had impaired motor control over their own tongue, and were compulsively shaking their own hands and opening and closing their fists. Their symptoms lasted less than 24 hours, and were resolved upon their receiving Medications A, B, and C, the following day. C1 did not require outside medical treatment for these adverse symptoms.

During the 01/15/2025 incident, S1 had direct key access to C1’s medication records and prescription labels, which they could have used to resolve their confusion. However, S1 did not attempt to consult these resources. S1 also did not summon/contact the Licensee (who was onsite but asleep at the time) for help. Interviews of S1 and Licensee aligned to show: S1 fully relied on Licensee to dispense clients’ pills/tablets from their labeled blister packs (i.e., the packages in which the pills/tablets arrive from the pharmacy) in advance. S1 was then responsible for independently handing the dispensed pills to clients in care, at a subsequent time. Although S1 did not personally remove the pills from the blister packs, S1 remained significantly engaged in assisting clients with self-administration of medications. Licensee had not trained S1 on “assistance with prescribed medications which are self-administered…as appropriate for the job assigned and as evidenced by safe and effective job performance,” as was required by regulation.