Complaint Investigation Report

According to medication records at the facility, Fentanyl was not a drug that was prescribed to R1 by a physician. Additional records obtained by IB reveal that R1 has a history of Possession/ Arrest of Illegal Substances. Witnesses stated they last seen R1 alive on 01/23/21 and 01/24/21. Records indicate that a pen with white substance was located near R1’s bed, and a prescription bottle with a scratched off label. Based on the information obtained during the course of their investigation, IB concluded that the allegation of suspicious death to be unsubstantiated. Therefore: Although the allegation may have happened, there is not preponderance of evidence that the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

Regarding Staff did not assist with Prescribed Medication Administration.

It was alleged that R1 wasn’t provided assistance with administering their medication throughout their stay at the facility. LPA reviewed the Medical Administration Record (MAR) and R1’s medications were observed to be taken as prescribed except for 2 days listed in which R1 refused. This was documented on the Medication Administration Record (MAR.) Therefore:; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Residents Personal property was stolen.

It was alleged that licensee failed to safe keep R1’s Xbox. During the investigation, LPA Observed that the personal property stated by Rp was stored and locked in the administrator’s office for safe keeping. The father of R1 was contacted and he came to retrieve the item. Therefore ; Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding Licensee did not make residents records available to the responsible party.

RP stated that she requested from the facility a copy of R1’s admissions Agreement, and Medication Log. The facility only provided R1’s admissions agreement. The facility stated that R1 was not conserved and could not release medical information without consent from R1. As R1 is considered the responsible party, and does not have a Court Appointed Conservator, or POA. During review of resident records, there was not documentation that indicated that the Resident was conserved by person or estate. The Medical Records requested were not a facility created document, and came from the Pharmacy with Residents Name, And Type of Medication. The document was not released due to Hippa. Therefore; Although the allegation may have happened or is valid there is not enough evidence to prove that the violation did or did not occur. Therefore; the allegation is unsubstantiated.