complaint·May 23, 2024

On 09/07/2023, Licensing Program Analyst (LPA) Mario Leon conducted an initial complaint investigation to address the allegation listed above. LPA Leon met with Peggy Clark, Administrator (S1), and explained the purpose of this visit. The investigation consisted of the following: LPA Leon toured the facility, and interviewed three (3) staff (S1-S3). LPA Leon requested and reviewed facility documents. Allegation(s): Staff did not get timely medical care for resident resulting in resident's death. The investigation revealed the following: Regarding the allegation “Staff did not get timely medical care for resident resulting in resident's death,” it is being alleged that Resident #1 (R1) complained of chest pain at 11:30 AM, R1 was assessed by the MedTech, R1 complained of continued pain and fear at 12:30 PM, and R1 passed away at 4:35 PM. Death Report reveals that a Caregiver contacted MedTech, MedTech took R1’s vitals, called hospice, and hospice said they could come out in about 4.5 hours. Hospice Communication log reveals that the hospice company received a call on 09/01/23 11:18 AM concerning R1’s symptoms and hospice provided instruction to the facility. Interview with the hospice representative, Witness #1 (W1), indicated that staff was instructed to supply R1 with oxygen. W1 indicated that staff verbally confirmed that oxygen was administered. Interview with staff indicated that oxygen was administered to R1 and the facility waited for hospice’s arrival from 09/01/23 12:30 PM to 09/01/23 4:30 PM. Hospice discharge summary reveals that the company received a call from the facility at 09/01/23 3:30 PM indicating that R1 was unresponsive and hospice doctor pronounced R1’s death at 4:35 PM. Regarding the allegation, “Staff did not get timely medical care for resident resulting in resident’s death, based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was reviewed and left with Assistant Administrator Peggy Clark.