Complaint Investigation Report

Review of facility procedure for, “Vital Sign Readings to Determine the Need for Medication,” stated the following:

· Facility Procedure: residents, who are physically and mentally capable of reading vital signs may take their blood pressure and pulse readings; a Physician or registered nurse (RN); a licensed vocational nurse (LVN) under the direction of an RN or physician.

· Per document, unlicensed care staff may not take vital signs but may assist with self-evaluation of vital signs.

Interview conducted with Care Services Director stated that R1's PRN "as needed" supplement oxygen was discontinued after they returned from a skilled nursing facility in 2025. Care Services Director further stated that prior to R1's discharge from the hospital in February 2026, the facility received correspondence stating that R1 no longer required scheduled oxygen or oxygen as needed.

Review of R1's facility documents showed that on 12/13/2024 and 12/16/2024, R1 received physician orders for supplemental oxygen and for an oxygen concentrator. Review of R1's medication authorization record (MAR) indicated that R1 received their oxygen from 12/17/2024 to 02/20/2025. Review of R1's paperwork showed that R1 was admitted to the hospital on 02/20/2025 for acute respiratory failure. R1's discharge paperwork dated 02/26/2025, stated that R1 briefly required supplemental oxygen during their stay but was weaned off to room air. Review of R1's physician medication lists for 04/10/2025, 01/27/2026, and 02/21/2026 did not show any orders for supplemental oxygen.

Based on record review, interviews conducted, and observations made, this allegation is Unfounded . A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report discussed and provided to Hospitality Services Director and Care Services Director. Signature on form confirms receipt of documents.