Complaint Investigation Report

During multiple interviews with outside sources, it was consistently stated that during breakfast, C1 was not able to hold their body upright while sitting at the table. According to outside sources, C1 was wobbling back and forth, side to side, and had to physically be held up to prevent C1 from falling over. The school nurse evaluated C1 and observed that C1’s eyes were dilated and that they were not able to stand or sit upright. During interviews with multiple outside sources, it was indicated that C1 had been attending the same school since September 28, 2020, (4.1 years ago) and school staff were very familiar with C1’s behavior. School staff determined that C1 was not acting their normal self and that C1 was not at their normal baseline. C1 was not able to participate in their normal school activities due to their physical and mental state. Based on their assessments, school staff called 911 and C1 was taken to the hospital by emergency medical personnel for immediate medical attention. School staff accompanied C1 to the hospital. During an interview with outside sources, it was indicated that nursing staff at the hospital reported that C1 had “elevated Depakote levels”. A detailed review of C1's medical records indicated that C1 was prescribed Depakote to treat a medical condition and to treat other psychiatric conditions. (Depakote is normally used to treat seizure disorders, and certain psychiatric conditions (manic phase of bipolar disorder). A review of the side effects of this medication was indicated on the warning signs as dizziness and drowsiness and if any of these side effects last or get worse, to consult with the doctor, or pharmacist promptly.

On Wednesday, August 14, 2024, C1 arrived at school in the same state as the prior day. After evaluating C1, the school nurse called 911 again and emergency medical personnel transported C1 to the hospital for immediate medical attention. A review of the discharge hospital notes indicated that C1 had altered mental status and was diagnosed with a bladder infection which is a type of urinary tract infection (UTI). C1 was prescribed antibiotics for the infection. In addition, the medication Depakote was adjusted, (decreased in dosage).

On Thursday, August 15, 2024, C1 arrived at school in a comatose state again. During interviews with outside sources, it was indicated that the school nurse, management, and teaching staff agreed that C1 was in an unstable condition to attend school. (Continue at LIC9099C)