Complaint Investigation Report

LPA investigated the allegation that staff neglect resulted in the death of resident. Resident #6 moved into the facility on February 12, 2021, and passed away on March 28, 2023. Per Park View Estates Move In Record dated February 12, 2021, and Medication Administration Records, R6 had diagnoses of Type 2 Diabetes Mellitus without complications, Vascular Dementia, unspecified severity and Essential Hypertension. R6 resided in Memory Care (MC). It was alleged that the oxygen concentrator was not working at time of R6’s time of death and that staff failed to check if it was working. Per initial interview with the hospice agency, R6 was receiving hospice services at the time of death and R6 passed away due to natural causes. The hospice agency provided the oxygen concentrator and if there were issues, a vendor would be called for repair. LPA interviewed a second witness who provided the death certificate. The cause of death for R6 was Heart Disease unspecified. Per interview with Witness #2 (W2) the resident passed away naturally and hospice was present. Thus the allegation that staff neglect resulted in the death of the resident is Unsubstantiated.

The Department investigated the allegations that the resident was not provided prescribed medication and that the facility was falsifying medication charts. It was alleged that Resident #5 (R5) went into seizures due to staff not ordering the medication. It was reported that staff would mark the Medication Administration Record (MAR) that the medication was given when it was not. R5 was not able to be interviewed since they no longer resided at the facility at time of visit. LPA reviewed Unusual Incident Reports and noted a seizure incident that occurred on August 23, 2022. It was noted on the Unusual Incident Report, submitted to the Department on August 24, 2022, that the resident took the anticonvulsant medication daily. LPA reviewed the MAR and noted that the anticonvulsant medication was given daily and initialed by various medication technicians (med techs).

LPA interviewed one of one staff and one of one witness who had knowledge of the incident. One of one staff denied the allegation. One of one witness stated the name of a former med tech who would falsify records and initial given medications. LPA confirmed the med tech named by the witness was the med tech initials on the Medication Administration Record for the incident on August 23, 2022. LPA was unable to interview the MedTech in question. When LPA asked the witness about the particular incident, the witness could not remember this happening. LPA interviewed one of one staff member present who could not recall the specifics of the incident. Thus the allegations that: Facility did not ensure resident was provided prescribed medication and Facility falsifying medication chart are Unsubstantiated. (Cont'ed on LIC 9099-C1)