complaint·June 16, 2023

Continued from 9099 Information gathered during the course of the investigation reflected that R1 was admitted to the facility on 08/24/2021, after previously residing at a skilled nursing facility. Upon admission to the facility, R1 was also assessed and admitted into ABC Hospice. Based on the Comprehensive Nursing Assessment completed by hospice staff on 08/24/2021, R1 was noted to be bed bound, with a primary diagnosis of Alzheimer’s disease and secondary diagnosis of restlessness, agitation, chronic pain syndrome, dyspnea, and hypertension. Additionally, R1 was further noted to be awake, but lethargic, minimally responsive, and disoriented. R1 was pulse was also noted to be regular but weak with labored respirations. Per the hospice assessment reviewed, R1’s family was present during the visit and a Physician Orders for Life-Sustaining Treatment (POLST), which indicated Do Not Resuscitate (DNR) was signed by the family of R1. The assessment further reflected that, R1 was actively dying, due to R1 being lethargic, and non-responsive to verbal and touch stimuli. R1 was placed on comfort care and were prescribed Morphine Sulfate, as needed (PRN) along with Acetaminophen (PRN), Amlodipine Pesylate, Lorazepam (PRN), Olmesartan Medoxomil and Quetiapine Fumarate (PRN). The hospice care visit notes for 08/25/2021, reflected that per facility caregivers, R1 was not drinking any fluids or taking any meals. Therefore, new orders were received from R1s hospice physician, and R1 was given Normal Saline (NS) via intravenous injection (IV). Per hospice records, R1 was given non-pharmacological methods to control pain on both 08/25/2021 and 08/26/2021. At approximately, 5:20 p.m. on 08/26/2021, hospice conducted an unscheduled visit after receiving a call from facility caregiver who reported that R1 was non-responsive to verbal, touch stimuli and had severe shortness of breath. Upon nurse assessment, R1 was cold to touch, had no pulse, respiration, and pupils were not reacting to light. R1 was pronounced deceased at 5:20 p.m. in comfort. Interviews conducted with R1’s family indicated that R1 was rapidly declining and actively dying upon admission to the facility and the family did not have any concerns of neglect or foul play by the facility. Based on information gathered throughout the course of the investigation, the Department does not have sufficient evidence to determine that R1’s death was expedited by facility staff. Therefore, the above allegation “questionable death” is deemed UNSUBSTANTIATED at this time. Exit interview conducted/ No citations issued/ A copy of report provided to administrator.