Complaint Investigation Report

Review of the facility and C1’s records as well as available correspondence, determined the placement agency did not arrange for the medications to be ready at the time of placement. When C1 was transferred to the facility they did not bring all of their medications. During staff interviews, it was indicated that despite their efforts to transfer the medications from the pharmacy to the facility, there was a delay due to problems with insurance coverage. In addition, neither the facility nor the pharmacy had current physician’s orders, which resulted in a delay in processing the prescription. Once C1’s attending physician placed new medication orders, C1’s medical insurance approved the prescription. On August 2, 2021, C1’s medications were delivered to the facility and staff were able to administer them as ordered. A review of CCL incident reports submitted by the facility regarding this incident indicated no violations of Title 22 regulations in the handling of this situation. In addition, Title 22 reporting requirements were met. A review of the incident reports submitted indicated no adverse reactions for not taking the medication as C1 did not express any agitation, anxiety, or aggression toward staff or clients during the period of this incident. Based on records review and staff interviews, once the staff had the current physician’s orders, medication was administered to C1 as prescribed.

It was also alleged that staff did not provide individual privacy to C1. It was specifically alleged that staff entered the bathroom while C1 was using it. Details of when this incident occurred, or which staff member was involved were not identified during the investigation. Multiple interviews with staff and clients did not disclose any evidence of staff entering the bathroom while any clients were using it. During a visit to the facility conducted on August 13, 2021, observations showed the doors to both of the bathrooms had locking mechanisms from the inside of the bathrooms.

Lastly, it was also alleged that facility staff did not treat C1 with dignity and respect. It was specifically alleged that staff did not allow C1 access to the facility telephone. An interview conducted on August 13, 2021, with C1, confirmed they were allowed access to the house telephone and did not support the allegation. C1 stated that the facility staff were nice and treated them with respect. Multiple interviews with staff and clients consistently indicated that clients had access to the house phone as needed.