Complaint Investigation Report

R1’s Medication Administration Record (MAR) indicates R1 is prescribed 2 capsules per day at 3:00 PM. R1’s MAR records R1 was given 2 capsules of M1 on 06/25/2024, 06/26/2024, 6/27/2024, and 06/28/2024.

R1’s MAR records R1 was given 2 capsules of M1 on 07/01/2024, 07/02/2024, 07/03/2024, 07/05/2024, 07/08/2024, 07/09/2024, and 07/10/2024. From 06/25/2024 to 07/10/2024, there were 11 days in which staff assisted R1 with the administration of 2 capsules of M1, which totals 22 capsules.

During visit on 07/11/2024, staff S1 counted R1’s M1 capsules in front of LPA Marrufo. The number of capsules in the bottle totaled 116. After subtracting 22 capsules from the 136 capsules in the bottle, there should have been 114 capsules remaining. However, there were 116 capsules remaining in the bottle. LPA Marrufo observed that the bottle did not have a start date written on it.

On 02/18/2025, LPA Marrufo conducted an interview with witness W1. W1 stated during interview that W1 brings R1’s M1 medication to the facility once every three months. R1 stated that on one occasion when he/she came to the facility to provide a new bottle of M1 to S2, the previous bottle of M1 had 61 capsules remaining, but there should have only been 2-4 capsules left.

During interview on 09/26/2025, S2 stated that R1's family member would come to the facility every three to six months and provide new bottles of M1. S2 stated that on one occasion, R1's family member came to the facility and retrieved two sealed bottles of M1. S2 stated to have counted the capsules of an open bottle of M1, but the number of capsules in the bottle was not too high. S2 stated that R1's family member provided a bottle of M1 on 06/25/2024. S2 stated he/she mistakenly recorded the start date of that bottle on 06/25/2024, but he/she started pouring capsules from that bottle on 06/26/2024. S2 stated that his/her mistaken start date is why there were 116 capsules in the bottle instead of 114 on 07/11/2024.

During interview on 10/10/2025, ADM stated that the facility policy regarding when a parent of a client picks up unused medications is that the staff responsible for the medications will review the medication count with the parent and sign out the medications.