complaint·June 20, 2023

team is SUBSTANTIATED. Allegation: Facility staff did not follow Resident #1 (R1) treatment plan for administration of oxygen. Interviews and record reviews conducted by the department revealed that on May 7, 2020, R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing, choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was hooked up to the wrong machine. S1 admitted that there was a “mix up with the machine”. S1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that they had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” Based on interview and records review the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. An exit interview was conducted and a copy of this report, and appeal rights were provided to Lisa Hunt, Executive Director. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that she had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” It was also determined that S1 failed to notify facility staff and the hospice agency of the mishap. S1 has received verbal and written counseling and the facility provided all staff training on the difference between an oxygen and nebulizer treatment. R1 was stable after the hospice nurse made their visit to the facility. Hospice staff noted that R1 was talking and seemed just fine the morning of their passing. The death certificate classified that the cause of death was “cardiorespiratory arrest with end state Alzheimer’s dementia.” There was nothing noted on the death certificate that the mix up with the nebulizer instead of Oxygen was a contributing factor to R1s death. The allegation of staff neglect contributed to the death of resident is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that 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. An exit interview was conducted and a copy of this report was provided to Lisa Hunt, Executive Director.