complaint·April 14, 2023

Orders indicated that two medications were to be discontinued. Per the R1's Medication Administration Records (MAR) for April 2022, R1 was given the discontinued from 4/19/2022 to 4/23/2022. Additionally, R1 was given the new medication from 4/20/2022 to 4/23/2022. Per R's death certificate, R1's date of death was 4/28/2022. The cause of death is listed as "Bradycardia, Metabolic Encephalopathy, and Dementia." The staff were interviewed and admitted to not seeing the note for the discontinued medication. R1 was admitted to ICU due to Hypoglycemia and hourly blood sugar check. An unusual Incident/Injury Report was submitted by Med Tech reported at 3:18 PM. on 04/23/22, R1 was leaning to their right side, sweating, and slowing on their speech, 911 was called and R1 was sent to the Emergency Room for further evaluation. On 4/21/22, R1 was transferred to the medical unit, became bradycardia, and went into cardiac arrest on 4/28/22. The death certificate indicated, R1's immediate cause of death was listed as "bradycardia" with underlying causes listed as "metabolic encephalopathy (An alteration of brain function or consciousness due to failure of other internal organs). R1 had new medications added and 2 medications needed to be discontinued per doctor's orders. S1 did not transcribe the discontinued orders into the facility’s Medication Administration Record (MAR) which caused the resident to be administered 2 medications which were discontinued per physician orders. Based on documents reviewed, interviews conducted, there’s no preponderance of evidence to prove the alleged violation contributed to resident’s death. No coroner's report was associated with R1's death as the cause of death was deemed to be of natural causes, therefore, this allegation is UNSUBSTANTIATED .