complaint·February 15, 2024

Allegation: Questionable death Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical documents showed that on 12/06/22, R1’s doctor received a fax from facility staff (S1) who notified him about R1’s cough and congestion. Staff requested for cough syrup and an appointment with the doctor. Lab tests were ordered and a chest x-ray was performed on 12/06/22. The results of the chest x-ray showed R1’s lungs were clear and the pleura unremarkable. On 12/06/22, staff (S2) also notified the doctor when R1 developed a fever and staff gave R1 Tylenol which reduced her fever to normal. Staff continued to monitor R1 and on 12/07/22 at approximately 0500 hours, R1 passed away. Documents obtained do not suggest R1’s death was a result of neglect or lack of care for suspicious circumstances from facility staff. Review of death report showed immediate cause of death was acute hypoxic respiratory failure. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of questionable death is unsubstantiated. Continued on next page, LIC 9099-C1 Allegation: Staff do not dispense medication to resident in a timely manner Investigation Finding: Unsubstantiated Review of R1’s centrally stored medication logs and medication administration records dated 06/27/22 showed that staff totally assisted R1 with prescribed medications daily. Staff documented medications, central storage and assistance with residents in their electronic database which recorded daily intake of prescribed medications by residents, reports to doctors of any resident medication refusal or any missed dosages and any changes to residents’ physicians’ orders. Prior interviews conducted by LPA on 03/08/23 with staff (S1) and residents (R2, R3) confirmed that staff gave total assistance with daily prescribed medications and dispensed medications to residents in a timely manner. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of staff do not dispense medication to resident in a timely manner and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not dispense medication to resident in a timely manner is unsubstantiated. Exit interview conducted and a copy of this report provided.