Complaint Investigation Report

On the allegation: Staff dispensed medication not prescribed to client in care. LPA conducted interviews with staff and resident which revealed R1 is supervised 24/7 at the facility and at R1’s day program by staff, staff do not feel R1 could have acquired any medications or street drugs from anyone during this time R1 has a 1 on 1 ratio with staff 24/7 at his facility and at R1’s day program which began in March 2025. LPA interviewed R1, R1 is verbal but R1 does not understand all questions asked or how to respond, R1 repeats word when asked questions. R1 stated R1 did not acquire any drugs from anyone, R1 stated Oh my God, oh no R1 feels a lot better now that R1 is home from the hospital and completed his round of new antibiotics. LPA De Leon reviewed all resident’s medication, Centrally Stored medications and Medication Administration Records. R1’s Psychiatrist made medication changes for R1 on 03/25/2025 and on 04/08/2025. R1 was seen on 03/27/2025 at Twin Cities Hospital for a laceration. R1 was not at baseline staff felt it had to do with R1’s medication changes and took R1 to Twin Cities Hospital, R1 was discharged and staff stated they felt it was due to the new medications being adjusted and if symptoms worsen return to the ER. R1 was having symptoms about a week later with stomach upset and Administrator took R1 to the hospital for those symptoms to see what was causing them. R1 was seen on 04/26/2025 at Twin Cities Hospital for those symptoms and was admitted for observation and testing, R1 was drug tested at this time and a trace amount of Fentanyl was found in R1 system. R1 was taking 13 medications that were doctor prescribed prior to hospital visit on 04/26/2025. Upon R1’s discharge from the hospital, the doctor from the hospital reviewed R1’s medications adding 1 new medication and discontinuing the use of 4 medications due to them having potential to cause adverse effects. According to R1’s medication list Risperidone was a medication prescribed by the R1’s Psychiatrist on 03/27/2025 and discontinued by the hospital doctor on 04/28/2025 per hospital discharge records. The medication Risperidone may cause false positive Fentanyl results on Urine Drug Tests, according to studies and R1’s other medication Haloperidol can also spark false positives on drug tests. Due to R1 not having access to other resident’s medications and R1 not able to leave facility or day program unassisted by staff, staff do not feel R1 could have gotten a hold of Fentanyl. LPA reviewed the medications at the facility and no residents were prescribed Fentanyl medications. LPA reviewed incident reports for the facility and the staff did not report any medication errors during this time. Facility has medication procedures set up to avoid having errors where they use 2 staff to check each other before helping residents self administer medications. Due to insufficient evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.