Complaint Investigation Report

R1 passed away on 12/17/2025 at 0446 hours. Based on death certificate, R1's cause of death was “combined toxic effects of multiple drugs including olanzapine and 9-hydroxyrisperidone.” Per R1s file records, R1 entered Oak Lane Center with 43 tablets of olanzapine. It is unknown how many tablets were remaining after R1 passed away. R1 received an injection of Invega Sustenna which was last received on 11/25/2025. Doctor advised that the therapeutic range for olanzapine is 20 to 80 ng/mL. R1’s level was 600 ng/mL of olanzapine. Based on medical records, R1’s olanzapine was about seven times, or more than R1 should have had in their system. Doctor advised that R1 would have had to take between 15 and 30 tablets within a short period of time to get the blood level they had. Doctor confirmed that Invega Sustenna and 9-Hydroxyrisperidone are the same medication. Facility staff reported R1 was compliant with their medication. Facility staff confirmed that the medication is locked and residents do not have access to their medication. Nursing staff are the only ones who provide residents with their medication. It was reported by residents and staff that R1 was sick leading up to their death. The timeframe R1 was sick was inconsistent; some reported R1 was sick for two weeks where some reported R1 was sick for a couple of days leading up to their death. Per Administrator, staff will strip resident’s beds and wash their sheets and pillowcases while the residents are in the community. There were no drugs found in R1’s room after their passing and when R1’s room was cleaned. The facility was unable to account for R1’s medications after their passing to determine the number of pills remaining. Therefore, the allegation Questionable death is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Report left with facility.