Complaint Investigation Report

Allegation: Questionable death. It is alleged that on March 10, 2026, resident (R1) pushed the necklace alert button ten (10) times and staff did not respond. The complaint alleges the resident then pulled the wall alert cord, staff responded and called paramedics who performed CPR. According to information obtained, the resident passed away and was left lying in the bedroom floor for approximately 9 hours with a CPR tool in their mouth until the coroner arrived at the facility. The Department investigated the allegation. According to staff interviews, a caregiver responded immediately and observed the resident was sitting on the bed complaining of chest pain. While the medication technician was getting the vital machine the caregiver reported to the medtech that the resident was seizing and had a change in condition. The caregiver was instructed to turn the resident on their side, and 911 emergency were immediately called and responded within two minutes. Life saving measures were provided for approximately 45 minutes, but the resident was pronounced dead at 5:17 AM. According to the death certificate, resident (R1's) immediate cause of death was non-traumatic brain injury and central nervous system suppression. Based on the interviews conducted and supporting documents, there is insufficient evidence to support the allegation.

Allegation: Staff did not respond to resident's requests for assistance in a timely manner. The complaint alleges that resident (R1) used the emergency call system several time over a lengthy period but facility staff failed to respond to R1's multiple requests while experiencing cardiac arrest. The Department investigated the allegation. The findings revealed that resident (R1) pressed the pendant four (4) times on March 10, 2026, at 2:15 AM, 3:55 AM, 4:06 AM, and 4:24 AM. A total of nine residents were interviewed, of which all reported that staff respond to pendant/emergency call system requests within a reasonable time frame of 5-15 minutes. According to staff interviews and record review, staff are to respond promptly to calls for assistance. Staff reported that depending on the situation sometimes staff respond immediately, and other times it may take a little longer if they are busy assisting other residents. Facility staff are trained to respond within 10 minutes or less. Based on the interviews conducted and call system record review, facility staff responded to R1's medical emergency accordingly in a timely manner. There is insufficient evidence to support the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated .

An exit interview was conducted and a copy of this report was discussed and provided to Colleen Rozatti.