complaint·September 16, 2024

Review of R1’s physician report dated January 2024 and pre-appraisal assessment records dated 1/27/2024 revealed that R1 did not have any memory impairment, had a diagnosis of heart disease, was confused, but able to follow directions and communicate needs, was not able to administer or store own medications and was not receiving hospice services. Review of facility progress notes for R1 revealed that in early February 2024, R1 was observed by facility staff to have a change in condition and was experiencing increasing confusion. R1 was transported to the hospital where R1 received medication and treatment for a urinary tract infection. On 2/21/2024, R1 expressed feeling drowsy to facility staff and staff notified R1’s spouse. R1’s spouse spoke to R1’s primary physician who requested that R1 be sent to the hospital. Facility staff called 911 and R1 was assessed to be lethargic and non-responsive by paramedics. Paramedics administered a Narcan injection and transported R1 to the hospital, where R1 was admitted and treated for a urinary tract infection. At the hospital, R1 tested positive for narcotics during urine analysis testing. R1 was discharged back to the facility on 2/23/2024 and was readmitted to the hospital on 2/24/2024 after displaying stroke-like symptoms. R1 was moved out of the facility on 2/27/2024 and review of R1’s death certificate revealed that R1 passed away on 3/5/2024 with the cause of death listed as cerebral atherosclerosis and unspecified heart failure. Additionally, R1’s death certificate did not list the presence of narcotics in R1’s urine, the Narcan administration on 2/21/2024, or any other conditions as having contributed to R1’s death. Review of R1’s medication record dated 2/29/2024 and interviews with facility staff revealed that R1 was not prescribed any narcotic medications and staff denied administering narcotic medications to R1. Interviews with facility staff revealed that all narcotic medications are stored in a locked cabinet in the medication room and are counted at the beginning of each shift by medication technicians. Interviews with staff and R1’s progress notes stated that R1’s spouse notified facility staff on 2/21/2024 that R1 had tested positive for narcotics and the Resident Care Director and medication technicians on shift conducted an additional narcotic medication count that day and did not discover any inconsistencies. Review of narcotic count records for February 2024 did not reveal any inconsistencies with narcotic medication counts for residents at the facility. Continued on LIC9099-C page... Interviews with an outside medical professional revealed that the administration of Narcan could cause a false positive on a drug screening. Additionally, the outside medical professional stated that the administration of Narcan and the potentially false positive narcotic result were not a direct cause of death for R1. Interviews with staff and outside sources and review of records did not reveal how R1 could have taken the narcotics. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Business Office Manager Virginia Rodriguez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).