Complaint Investigation Report

Hospice Nurse 2 reported that if they ever suspected facility staff from neglecting or causing or contributing to someone’s death, they would report it. R1’s responsible party reported that they were called on December 25, 2025, about R1’s condition and on December 28, 2025, they were called so they went to visit R1. R1’s responsible party reported they were present when R1 passed away and didn’t recall specific details about the care that was provided to R1 on that day. R1’s responsible party reported that they never witnessed any actions by staff that were abusive or that could have led to R1’s death. Hospice Nurse 2 reported they don’t remember any issues with R1 or the facility that would be a cause for concern. Hospice Nurse 1 reported that they never witnessed any issues or had a cause of concern for R1 or the facility. Hospice Nurse 1 reported that they don’t believe anything the staff did contributed to the death of R1. Staff 2 (S2) was present at the facility when R1 passed away but reported they were caring for the other residents and weren’t involved with R1’s care that day. S1 reported that after Hospice arrived, they handled all of R1’s care needs. Hospice Nurse 1 verified this information. R1’s death certificate lists R1’s cause of death as Alzheimer’s Disease with Late Onset, on December 28, 2025, at 5:20 pm. No other contributing factors are listed. Hospice records for R1 dated December 18, 2025, state, “Over the past 15 days, the patient has exhibited a continuous and progressive decline in condition, consistent with the terminal trajectory of their end-stage disease.” None of the evidence gathered supports the allegation.

Based on the evidence gathered through interviews and documents reviewed the allegation is deemed unsubstantiated , meaning that, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff did not ensure medication records were properly managed, revealed the following. It was reported that R1’s medication records were not properly recorded and documented. R1’s physician ordered R1’s medications to be crushed because of R1’s difficulty with swallowing. A review of records show R1 had routine medications and PRN medications (as needed) and a Hospice comfort kit of medications administered by Hospice Nurses stored at the facility including Morphine 20ml solution. A review of Hospice records show R1 was prescribed a total of 24 medications. Facility records show R1 was prescribed a total of 24 medications. Staff 1 and Staff 2 reported that R1’s medication records were current and reflected all of the medications they were prescribed. At the time of the initial 10-day visit (December 31, 2025) R1's medications were no longer at the facility and had been returned to the pharmacy, so R1's medications could not be inventoried.