complaint·June 10, 2021

intertrochanteric femur fracture, acute kidney injury on CKD stage 3, acute blood loss anemia on chronic normocytic anemia, and failure to thrive. According to Suncrest Hospice records, the primary diagnosis was protein calorie malnourishment and a Hospice Physician stated that R1 had a terminal illness with a life expectancy of six months or less if illness follows its usual course. On 3/8/21, Hospice Physician indicated that R1 has declined precipitously since a complicated heart surgery, broken femur and other injuries. On 3/12/21, R1 began transitioning, had no intake for 5-days, and was non-responsive to verbal or tactile stimuli. According to interviews with Hospice staff and Hospice records, Hospice nurse began providing 0.5 ml of Morphine to regulate R1's breathing, as R1 began having rapid shallow breathing. According to interviews with Hospice staff, the Hospice Aids would provide assistance with daily living (ADL's), which includes bathing/bed baths, incontinent care, nail care, dressing, linen change, denture care, skin care, foot care, documenting bowel movements, and repositioning patient. Also, according to interviews with Hospice staff, the Hospice Nurse typically provides care, which includes administering medications, once or twice per week, however, due to R1's rapid decline, the Nurse provided care once or twice daily. Interviews indicated that the Hospice Nurse provided R1 with medications. On 3/15/21, Suncrest Hospice was notified that R1 had stopped breathing at 0637 hours. Hospice Nurse arrived at the care home and pronounced R1 deceased at 0732 hours. Medication disposal was conducted by the Administrator and Hospice Nurse on 3/15/21. Sacramento County Death Certificate issued on 4/5/21, indicates R1's date of death as 3/15/21 and cause is Acute Diastolic Congestive Heart Failure. The Death Certificate did not indicate a cause of death pertaining to medications. Based on documentation reviewed and interviews conducted, 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit. Exit interview conducted.