Complaint Investigation Report

On 03/13/26, between 9:36 a.m. and 3:30 p.m., the LPA conducted a telephone interview with one (1) staff, conducted a file review, and collected pertinent documents relevant to the investigation. During today's visit the LPA conducted one (1) phone interview with former staff, attempted to conduct phone interviews with Client 4 (C4), and one (1) witness, conducted a file review and collected pertinent documents relevant to the investigation.

Regarding the allegations, “Staff are not ensuring residents are provided their medication as prescribed and Staff are not properly documenting the MAR,” it is the concern of the Reporting Party (RP) that staff failed to ensure residents received medications as prescribed and failed to properly document the Medication Administration Record (MAR). Specifically, the Reporting Party (RP) expressed concerns regarding medication errors during client crises, improper documentation leading to double-dosing, and the administration of medications without valid prescriptions.

The RP reported that on 05/09, (no year was provided) a client received 1.0 mL of Testosterone instead of the ordered 0.2 mL. Program Director Nicole Lomeli and a review of the Kipu EMR system could not identify a client matching the specific name provided by the RP. However, a client (C4) with a similar nickname was identified as receiving Testosterone. During a phone interview, the Director of Nursing (DON) revealed they were unaware of any errors involving C4. During a phone interview, Staff 2 (S2) recalled C4 requesting a dose reduction from the prescribed 200mg, but S2 denied deviating from the doctor's order and stated the client was advised S2 could consult their physician. C4 has since discharged; the LPA attempted to contact C4 via telephone but was unsuccessful.

The DON confirmed that on 11/18/23, Client 2 (C2) received a double dose of Adderall (60mg total). The error occurred because the NOC shift nurse administered the morning dose but failed to record it in the narcotic binder. Consequently, a Mental Health Technician (MHT) administered a second 30mg dose later that morning. The DON stated C2 was monitored, remained asymptomatic, and the physician was notified.

The DON also confirmed that on 03/16/25, Client 3 (C3) was administered Suboxone 12-4mg without a current order. C3 was prescribed Subutex, but staff substituted Suboxone from existing stock because the client had previously been on that medication. Report will continue on LIC9099-C, third page.