Complaint Investigation Report

Administrator had appointment on 11/20/2025 for R1 with R1's Psychiatrist. R1's Psychiatrist changed psychiatric medications by discontinuing the Quetiapine and Sertraline once the new medications Cobenfy arrived at the facility. The new medication Cobenfy was not filled right away due to the pharmacy getting a denial from the insurance and the medication needing prior authorization, the pharmacy technician had to call the doctor to get the authorization to be covered by insurance, this was finalized on 12/01/2025 and then filled by the pharmacy. The medication was sent overnight by FedEx and arrived at the main office of the facility on 12/02/2025 at 3:00pm. Administrator picked up the medication from the office on 12/03/2025 and updated the medication records to discontinued the Quetiapine on 12/03/2025 and discontinued Sertraline on 12/04/2025. R1 had another appointment with Psychiatrist on 12/04/2025 for follow-up. The Administrator added the new medications into R1's CSMDR and MAR for Cobenfy to start on 12/04/2025 at 50-20mg 1 capsule by month twice daily for 7 days then after the 7 days to start Cobenfy at 100-20mg 1 capsule twice daily. Staff took R1 to the urgent care on 12/09/2025 R1 was having some allergies /or reaction at that time. Urgent care ordered two additional medications for R1 an eye drop and a nausea medication. Administrator contacted R1's Psychiatrist and reported the allergy, Psychiatrist discontinued the Cobenfy on 12/09/2025. Psychiatrist added a PRN on 12/09/2025 of Lorazepam 2 mg tablet maximum of 2 per day for R1 and according to the MAR it was given December 21st, 22nd, 23rd, 25th and 26th 1 time on each day. Administrator made a follow up appointment for 12/17/2025 with R1's Psychiatrist to follow up on the allergies and the Psychiatrist ordered a new medication Risperidone to take in place of the Cobenfy that was discontinued. R1 had remained on Clonazepam through out November and December of 2025, it was never discontinued and according to the MAR it was given per physicians direction for the months of November and December 2025 and R1 had a PRN order for Lorazepam. According to the pharmacy's doctors orders the facility did not mishandle the medications they were started and stopped according to R1's Psychiatrist. The facility staffed complained to the Administrator that R1 was still having behaviors after starting the Risperidone and PRN Lorzepam, R1 has another appointment with Psychiatrist on 12/29/2025 to follow up on R1's new medications and behaviors. Based on the evidence the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.