complaint·January 9, 2025

Page 2 Allegation: Resident (R1) in care sustained unexplained medication overdose. FM1 stated that R1 was admitted to the facility on 1/10/23. On or around 1/15/23, S1 called FM1 and informed FM1 that R1 was refusing to eat and participate in activities. Approximately 4 to 5 days after admission, FM2 received a call from facility staff saying R1 was not eating, drinking, or getting out of bed. FM2 stated that on or around 1/20/23, FM1 and FM2 received a call from S1 informing that R1 will be send out to the hospital. Prior to arrival to the hospital, the Emergency Department (ED) doctor called and told FM1 and FM2 that R1 was poisoned by Lithium and that R1 was dehydrated. Medical records showed R1 was brought into the hospital on 1/21/2023 with Lithium toxicity and an acute kidney injury. The lithium toxicity caused R1 to have an altered mental status while the acute kidney injury was caused by poor food/fluid intake. R1 refused to take her medications at various times on 1/13/2023, 1/14/2023, 1/19/2023 and 1/21/2023. Staff who were interviewed all stated R1 refused to do anything, refused to get out of bed and refused to eat and drink throughout her stay at the facility. Resident Services Director (RSD) assessed R1 at home prior to R1’s admission and R1 was independent and able to do a lot of things on her own. However, after R1’s admission, R1 changed, became depressed and only wanted to stay in bed. R1’s refusal to get out of bed, eat and drink and do anything contributed to her condition leading her to be hospitalized. R1 stated she had been taking Lithium for over 5 years. R1 admitted not eating and stated that staff brought food to R1’s room and tried to be feeding her but does not remember if she drank fluids regularly while at the facility. The medical records confirm that R1 was admitted for lithium toxicity. The medical records do not indicate a cause, however, FM1 stated that lithium must be accompanied by adequate liquid intake, otherwise it accumulates in the body. Staff reported that R1 was not eating and drinking regularly. It was found that R1 had medication orders for the lithium and the facility’s Centrally Stored Medication and Medication Administration Records were in order. The facility med-tech stated having provided all medications as ordered by the primary care physician (PCP). Therefore, the allegation is unsubstantiated. ....continued on 9099C (page 3) Page 3 Allegation: Resident (R1) became severely dehydrated while in care. All staff interviewed stated R1 refused to eat and drink during the 11 days R1 resided at the facility. R1 had two sips of an 8 ounce cup of water when her medication was administered to her. Staff noticed that R1’s water cup and water pitcher were barely touched. R1 drank juice that was offered to her and ate approximately 15%-25% of food that was served to her. All staff stated having made attempts to encourage R1 to eat and drink during her meals, even feeding her. R1’s refusal to eat and drink contributed to her worsening condition. Staff noticed R1 had cracked lips and was not eating or drinking much. They knew R1 needed water/fluids for her medications. R1 stated she had been taking Lithium for over 5 years. R1 also stated that Lithium is a form of salt and taking this medication would require one to drink a lot of water to have it released from one’s body. R1 admitted to not eating and drinking consistently and stated that staff brought food and liquid to R1’s room and tried feeding her but does not remember if she drank fluids regularly while at the facility. No information emerged to indicate that staff were not attempting to have R1 drink liquids. Therefore, the allegation is unsubstantiated. Based on records review and interviews, both allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citation issued. Exit interview conducted and copy of this report provided.