Complaint Investigation Report

Records and interviews showed: Near the end of February 2025, Licensee self-recognized that C1’s pharmacy had not yet delivered to the facility refills of C1’s once-daily Aspirin and Bupropion medications to cover March 2025. Licensee contacted both C1’s pharmacy and the office of C1’s prescribing psychiatrist trying to resolve these issues. Licensee was told these refills could not be dispensed because C1’s psychiatrist needed to first authorize their replenishment. Also, C1’s pharmacy on 02/28/2025 contacted the prescribing psychiatrist's office directly to advise them of the situation and to seek clarification regarding medication orders. Despite constructive knowledge that C1 was about to run out of Aspirin and Bupropion pills, C1’s psychiatrist insisted they needed to first meet C1 for an appointment, and the next available appointment would not be until 03/26/2025. C1 subsequently attended an in-person appointment with their psychiatrist on 03/26/2025, after which point the doctor released the refills. Supplies of C1’s Aspirin and Bupropion pills were delivered from the pharmacy to the facility on 03/27/2025, at which point Licensee’s staff resumed giving these two medications to C1. CCLD concluded that the psychiatrist’ actions, from a practical standpoint, constituted a hold/pauser order. Licensee was therefore not culpable for C1 not receiving their Aspirin and Bupropion pills from 03/01/2025 through 03/26/2025.

Although C1’s missed Aspirin and Bupropion doses during March 2025 were not, strictly speaking, “medication errors,” the sudden/unplanned interruptions of these medications was required to be reported to C1’s authorized representative (who was their SDRC coordinator). Interviews of facility managers and SDRC personnel confirmed they were not timely reported, either verbally or via written report. SDRC personnel self-discovered the interruptions during their 03/27/2025 facility inspection/audit

Interviews of Licensee and San Diego Regional Center (SDRC) personnel, corroborated by SDRC records, further showed: Licensee staff on 04/21/2025 did not give C1 their once-daily routine Ferosul (iron) tablet in the morning, as prescribed. SDRC personnel discovered this during a site visit that day, bringing it to the attention of Licensee. Licensee thus gave C1 their Ferosul tablet on 04/21/2025 in the afternoon, which was late (i.e., not at the prescribed time). This constituted a medication error, which Licensee reported to C1’s prescribing doctor, and which Licensee subsequently timely reported in writing to SDRC and CCLD via Special Incident Report (SIR), as required.