complaint·February 21, 2024

After admission to the hospital. R1 was diagnosed with a pulmonary embolism. Interviews with five (05) out of six (06) staff members revealed that in the days leading up to the event, R1 had not reported any signs of labored breathing, shortness of breath, or other health-related conditions. R1 did report labored breathing to a family member (F1) on 01/09/2024. R1’s hospice nurse (H1) was called for an assessment. Interview with H1 at 11:00 a.m. on 01/19/2024 revealed R1 reported shortness of breath on the morning on 01/09/2024, but R1 had no visible signs of distress when H1 arrived. R1’s vital signs were taken and were normal. R1 reported no pain to H1 during the visit. H1 ordered additional medication for R1. F1 called 9-1-1 for R1 and R1 was taken to the hospital. Record review of R1’s care plan revealed facility staff and the hospice agency had followed all protocols outlined for R1. Based on interviews and record review, R1 did not report any sign of distress to staff, and R1’s vital signs were normal, indicating no medical attention was necessary. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.