Complaint Investigation Report

During initial interview W2 stated that emergency services wasn’t called in a timely manner being S1 called R1’s responsible party first and was then instructed to call 9-1-1. W2 further stated R1 was found unconscious and there was not an attempt to resuscitate. S1 stated during interview that due to R1 expiring of natural causes the responsible party was contacted first. S1 stated she was at the facility but was not able to provide what other staff were present.

Allegation: Facility staff did not provide consent documents to emergency providers.

W1 stated during interview that R1 had a physician order for life-sustaining treatment (POLST). W1 stated a lady (unknown name) handed her papers. S1 stated the facility did not have any of R1’s documents and was unsure who took the documents from the facility. During record review of the physician orders for life-sustaining treatment (POLST) dated January 12, 2024, indicated to attempt to resuscitate.

Allegation: Facility staff did not notate resident's medications that were taken.

W1 and W2 stated the facility did not notate any of R1’s medications that were taken. Both feel some of the medications were missing, but it is unknown if R1 had taken the medications or someone at the facility. W2 stated documents were given to W1 and did not indicate that R1 had taken any medications during the time she was there. S1 stated the facility did not have any of R1’s documents. LPA reviewed the medication administration record that was dated May 1, 2025, to May 31, 2024, and there was not any date noted where the