Complaint Investigation Report

Resident One (R1) Hospice Agency record review reveals on 01/25/2024, a hospice RN documented they found an unused fentanyl patch on the kitchen counter that was accessible to residents in care. Hospice RN documented they destroyed the fentanyl patch. Therefore, based on interviews, observation, and record reviews, the allegation “Staff did not ensure that medication was inaccessible to residents in care” has been deemed SUBSTANTIATED at this time.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited pursuant to Title 22, regulation 87464(h)(2) .

An exit interview was conducted where a copy of this report was reviewed and provided along with LIC9099-D and Appeal Rights.