Complaint Investigation Report

On 4/27/25, LPA interviewed 1 client (C5), and reviewed C1-C5’s Individual Program Plan (IPP).

Allegation: Staff are not dispensing medications as prescribed

The details of the complaint allege that the physician recommended a tapering of Abilify for C1 from10mg to Abilify 5mg on June 13th, 2024, and a stop of Abilify 5mg on July 8th, 2024. It is alleged that the medication was not stopped as of September 13, 2024. The complaint also alleges that in 2022, the time C1 takes the prescribed Levothyroxine 112mcg was not consistent with the doctor’s orders.

On 4/15/25, LPA Lee conducted a telephone interview with Zoe Wilson, Administrator (A1), who denied the allegation stating that C1’s conservator had a private meeting with Psychiatrist and requested medication changes. The prior Administrator was unavailable at the time of planning where the tapering of the medication was discussed. The facility discontinued the medication when Physician’s order came through. A1 stated, “we continued the orders as prescribed until a new order was issued in September 2024.” A1 further stated that “once the changes were made known, and the order sent to us, is when the medication was changed.” Lastly, A1 shared that facility staff receives training on medication procedures: during the on boarding process, hand on training after on boarding, and annually.

On 4/18/25 and 4/21/25 LPA Lee conducted telephone interviews with 5 staff (S1-S5). 5 out of 5 stated that they have always given medication as prescribed and have never given medication that has been discontinued. Lastly, 5 out of 5 stated that they have had medication training but 3 out of 5 was unable to say how often the training is repeated.