Complaint·September 10, 2021

Investigator Miles conducted interviews with R1’s relative on 10/30/2020 at approximately 1240 hours, caregivers on 11/06/2020 at approximately 1221 hours to approximately 1405 hours, Licensed Vocational Nurse (LVN) and Memory Care Director on 11/24/2020 at approximately 1200 hours, R1’s Primary Physician on 11/25/2020 at approximately 1147 hours, and Director of Health and Wellness on 12/10/2020 at approximately 1100 hours. Community Memorial Hospital Medical records for R1 were reviewed on 10/29/2020. Information contained in the records revealed that on 08/07/2020 R1 was found to be lethargic and hypotensive. R1 was admitted to the Intensive Care Unit (ICU) with sepsis and/or septic shock, lactic acidosis, and urinary tract infection (UTI). R1’s urine appeared grossly purulent; also known as, pyuria and UTI “is most likely” the cause of the sepsis. Medical records did not state the duration of the UTI present in R1’s body. R1 expired in the morning on 08/16/2020. Based on R1's physician’s professional medical opinion, due to R1’s severe dementia, on-going health conditions/issues, and age were factors that would not allow R1 to verbalize any type of pain or sensation in the urethra. Since R1 was incontinent and wore diapers, R1 was more susceptible to UTIs at any given time. The physician stated without a proper urine analysis/test, it would have been hard to determine the presence of a UTI. The caregivers interviewed did not observe any signs of a UTI present in the diaper; nor did they observe anything unusual with R1’s urine or stool throughout the week of 08/03/2020 to 08/07/2020. Based on the information and documentation provided, there is not enough evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted, today's report was reviewed and emailed to the Administrator.