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- Complaint
- Complaint received stating client was given the incorrect dose of medication which lead to increased aggression and harm to others. Client was then discharged, and parents were notified via email that they had 72 hours to pick the patient up, 15 hours away. No aftercare plans were made.
- Licensing follow-up: Licensing reviewed client records. Client was admitted on 11/28/22 and arrived with limited paperwork and bottles of pills (a 60 mg bottle and 80 mg bottle). The nurse assumed the 80 mg bottle was the current dosage, but the actual dosage prescribed was 140 mg. The APRN signed off on the medications after reviewing and adjusting them the following morning. The guardians were notified of the adjustments but were not provided a full list of current meds which would have reflected the lower dose of the specific medication she arrived with. Client exhibited violent behaviors throughout her stay, prompting an emergency 72-hour discharge on 12/20/22. The guardians were then provided a list of medications upon discharge, and they discovered the incorrect dose of medication. CEO advised that the client had several aggressive/violent behaviors at her previous facility, therefore, the facility does not believe the medication changes caused behavior prompting emergency discharge. Licensing investigated this complaint and provided TA on 01/04/23 regarding standard 902.10.f. Licensing complaint unfounded. DON stated that moving forward, the facility plans to complete a nurse review and medication reconciliation for each new resident to ensure meds/dosages are correct and will follow-up with guardian to ensure accuracy.
