complaint·May 8, 2025

Report Continued from LIC 9099... It was alleged that facility staff are providing medication to resident without physician’s order. It was reported that Resident #1 (R1) had been given prescription medications at the facility against the orders of R1’s physician and without a valid prescription. Additionally,it was reported that facility staff administered medication to R1 without a doctor’s order in an attempt to chemically sedate the resident. These medications were said to cause R1 mental distress and behavioral changes. Records reviewed and interviews conducted revealed that R1 had become more disruptive than usual and harder to redirect while attending the day program around April–May 2024. According R1’s physician's report dated 08/11/2022, R1’s primary diagnosis were autism spectrum disorder and mild cognitive impairment. The report also indicated that R1 experienced confusion, disorientation, and exhibited inappropriate and aggressive behaviors. However, the resident did not have any medications prescribed by their physician. Staff interviews revealed that R1’s family was informed of the resident’s behavioral changes, which included signs of sundowning in the afternoons and what appeared to be panic attacks. Staff stated that both R1’s family and paramedics were contacted during these episodes; however, either R1 or R1’s family declined hospital transfer. As an alternative, staff suggested hiring a personal companion, which the family agreed to try in hopes of alleviating R1’s symptoms. Staff interviews further revealed that all medications are administered strictly according to doctors’ orders and staff denied giving medication to any resident without a valid prescription on file. On 11/09/2024, during a behavioral episode, 911 was called and R1 was transported to the hospital for evaluation. While hospitalized, R1 underwent testing for the presence of any drugs or substances in their system; all test results came back negative. Furthermore, interviews with other residents indicated that they were receiving their prescribed medications without issue and reported no concerns about living in the facility. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation of “facility staff are providing medications to resident without physician’s orders”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. A copy of the report was issued.