Complaint Investigation Report

Allegation #1: Staff neglected resident while in care which resulted in overdose/hospitalization.

The complaint alleged that the client was brought to Riverside University Hospital System (RUHS) on February 15, 2024, due to concerns about a possible overdose. On June 15, 2026, the department interviewed staff member S1, who denied the allegations, stating that the client did not experience an overdose. The facility contacted Medical Emergency (ME) on February 15 because the client was unable to walk steadily. During the call, S1 provided ME with the client's history and confirmed that the client had received only the prescribed medications in their exact doses that day.

On June 15, 2026, the department also interviewed the Placement Agency (PA) regarding the complaint. The PA reported receiving an Unusual Incident Report and assessing the client upon receipt of the complaint. The department's review of the client's records for the RUHS confirmed admission on February 15, 2024. The department also examined the client’s Medication Administration Records from January 26 to February 15, 2024, and found no discrepancies. On June 15, 2026, the department was unable to interview client C1 because C1 no longer resides at the facility. On the same day, the department attempted to interview C2 but was unable to do so due to C2's health condition.

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 unsubstantiated.