Complaint Investigation Report

Regarding the allegation: Questionable death. On 12/06/2021, the Department received a complaint alleging that the facility caused the death of Resident #1 (R1) by overdosing R1 with morphine. Per record review, R1 was admitted to the facility on 09/28/2021 and received hospice services up until R1’s death on 12/01/2021. Per record review, R1’s Doctor’s Worksheet for Certificate of Death listed R1’s cause of death A) Cardiorespiratory arrest B) Dementia lewy body C) Atherosclerosis heart disease D) HTN. Record review of R1’s Pathology report dated 03/21/2022 did not include any abnormalities that could be a raise for concern. Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the care of R1. R1’s POA stated that R1’s POA was at the facility every day prior to R1’s death and had no issues with the intake of R1’s morphine. R1’s POA stated that R1’s POA communicated with R1’s doctors and hospice agency regarding R1’s medication and R1’s POA was in charge of R1’s medical care. Interview with the Licensee revealed that R1’s POA was very involved in R1’s care and medical care. The Licensee stated that the amount of morphine was given to R1 as instructed by R1’s doctor. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Resident not accorded dignity in relationship with staff. On 12/06/2021, the Department received a complaint alleging that the facility staff were "mean" to Resident #1 (R1). Interview with R1’s POA on 12/10/2021 did not raise any concerns regarding the treatment of R1. R1’s POA stated that the facility staff were “wonderful and the care was phenomenal.” Interview with the Licensee did not reveal any issues between staff and R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.