Complaint Investigation Report

Staff Statements S1 to S5: Clients generally self administer medications with staff assistance. Occasional refusals were noted, providers/prescribers are notified, and responsible party (RP) are informed. Most staff were unaware of any medication errors, except S5, who identified a dosage discrepancy during C1’s first week. The error occurred due to a mismatch between the prescription e-portal and the facility’s patient portal, resulting in C1 receiving 25 mg instead of 100 mg from 05/23/25–05/27/25. The correct dosage was confirmed and updated after consultation with C1’s provider. S5 acknowledged the oversight and noted that C1 has knowledge of the incorrect dosage and did not inform staff.

Client Statements C1 to C5: C1 stated there was confusion regarding dosage and tablet count and did not notify staff. Documentation shows C1 declined medication on 05/21. Other clients (C2–C5) reported consistent access to medication and no missed doses.

Document review confirmed that C1’s written order on 05/19/25 listed 1 tablet of 25 mg daily but an increase to 100 mg was noted without updating the official order form, contributing to the error.

Staff are not reporting incidents to the proper agencies.

Staff Statements S1 to S5: Staff reported that incidents are documented and communicated according to protocol. S1 stated all incidents are reported to the appropriate agencies, including CCLD, and responsible parties are notified of behavioral changes. S2 confirmed responsible parties are informed when clients request to leave. S3 indicated incidents are reported to the director, who then notifies agencies. S4 explained that medication discrepancies, such as dropped or missing pills, are logged and reported to the director. S5 stated medication errors are reported to the client’s provider and the director.

Client Statement C1 to C5: C1 alleged that an altercation involving two clients was not reported by staff. Other clients (C2–C5) reported no significant incidents, however, C5 noted a minor argument that resolved quickly.