Complaint Investigation Report

The Complaint alleged that on a day in early June 2021, they observed C1 appearing drowsy and overmedicated. They said C1 couldn’t finish their sentences or walk without swaying/nearly falling. The Complainant said C1 had started on new Haldol and Thorazine medications since moving into the facility back in March 2021.

According to C1’s LIC602 Physician’s Report, C1 was diagnosed with both developmental disability and mental disability. Per C1’s Individual Program Plan (IPP), which San Diego Regional Center (SDRC) wrote before C1 even moved into Esperanza’s Homes of Hope: C1 had a history of AWOL (i.e., exit-seeking / running away) behavior and when upset tended to display “emotional outbursts including yelling, cursing, stamping [their] feet, pushing staff, physical aggression, spitting at others, self-injury attempts (hitting her arm and legs, pulling [their] hair, and banging their] head), and property destruction.” C1 had already been taking “prescribed behavior modification drugs,” to include “antipsychotics” and “antidepressants,” prior to move in.

LPA interviewed C1’s assigned SDRC Coordinator/Social Worker, who confirmed that C1 had challenging AWOL behaviors, and that C1’s psychiatrist recently added/ordered Haldol and Thorazine to C1’s list of prescribed medicines. The SDRC Coordinator had no knowledge suggesting facility staff had deviated from physician’s orders. LPA interviewed C1’s responsible person (RP), who confirmed that C1 had challenging AWOL behaviors at their last residence (just before moving into Esperansa’s Homes of Hopes), and stated that any medication increases for C1 around this time were likely justified/warranted. C1’s RP had no knowledge suggesting facility staff had deviated from physician’s orders during this time.

LPA reviewed C1’s Medication Administration Records (MARs), which showed: Starting 03/25/2021, C1’s psychiatrist prescribed them a routine 50 mg/ml Haldol intramuscular injection once every two weeks, but by 04/16/2021 had discontinued it. Starting 03/25/2021, C1’s psychiatrist prescribed them an as-needed Thorazine 50 mg tablet up to once every four (4) hours, but by 04/16/2021 had replaced it with a routine 100mg tablet four (4) times per day. There was nothing in C1’s MARs to suggest that C1 received more Haldol than prescribed during the time that order was active. There was nothing in C1’s MARs to prove that facility staff were too liberal with giving C1 Thorazine during the time it was an as-needed (PRN) prescription. There was nothing in C1’s MARs to prove that facility staff had given C1 more Thorazine than prescribed even after it became a routine prescription. [CONTINUED ON LIC 9099-C, 2 of 2]