Complaint Investigation Report

It was alleged that staff overmedicated resident. It was reported that Client #1 (C1) experienced an overdose during the month of August 2024. Records reviewed including C1’s Controlled Medication Dispensation Records (CMDR) and Medication Administration Records (MARs) from July, August, and September 2024, revealed that C1 underwent numerous medication changes as directed by their doctor. Medication orders observed in C1’s file confirmed that the prescribed medications were accurately documented. A review of the CMDR and MARs showed that the administration dates matched the doctor’s orders for start and discontinue dates. Additionally, client progress notes dated August 2024 indicated that C1 was compliant with their medications, requiring few or no prompts, did not exhibit any emotional outbursts, and appeared calm throughout the week. Interviews conducted with clients revealed that medications are administered as prescribed. Furthermore, during client interviews, Ci denied ever receiving more medication than prescribed while residing at the facility. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff overmedicated resident”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff did not report incident to authorized representative. It was reported that Client #1 (C1) is conserved; however, incidents pertaining to C1 are not being communicated to their conservator. Records reviewed indicated that C1 was admitted to the facility on 04/30/2024. Per physician’s report dated 04/11/2024, it lists C1’s primary diagnosis as unspecified schizophrenia. The report further noted that C1 did not present with confusion or depressive symptoms and demonstrated the ability to follow instructions and communicate effectively. Furthermore, an appraisal/needs and service plan dated 05/02/2024 noted that C1 had been recently released from conservatorship prior to admission to the facility. Interviews conducted with staff corroborated the documentation, as staff confirmed that C1 was not conserved. They also stated that while clients have emergency contacts on file, medical information is not disclosed without proper consent or documentation. Additionally, staff noted that clients are typically the ones who choose to share their own information with family members. Furthermore, during client interviews, clients reported sharing information with their family members despite not having a conservator or responsible person. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff did not report incident to authorized representative”. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. Report was reviewed and copy was provided.