Complaint Investigation Report

9099C(1).. that packages are checked when dropped off, based on prior experiences. Family members indicated they recall staff (S1) stating that S1 would take the bags to R1’s room. S1 was interviewed and stated she only checked one of the bags, which had a black computer tablet and candy. Staff interviews were conducted which provided conflicting information. Some staff indicated that staff are responsible for checking gifts or asking the contents of the package and logging packages to ensure there are no hazardous items while some staff stated that packages are only checked if they are notified by family or suspect something hazardous in the package. Administrators and staff were unable to provide a written policy .

Based on medical records reviewed, On 5/10/2020, R1 was admitted to the hospital with the initial complaint of a stroke, but after further testing, resident was diagnosed with liver failure. Resident's labs were drawn on 05/11/2020 which showed resident’s Tylenol to be at 265 microgram/ milliliters. The normal range for Tylenol is 0-30 microgram/milliliters. Based on interviews conducted, if R1’s labs would had been drawn at the time of arrival, it would have been significantly higher but since Tylenol metabolizes, the level was lower at the time the blood was drawn. Interviews indicated R1 had an acute ingestion of taking over 100 pills at one time.

Based on toxicologist interviewed, it was confirmed that R1 had elevated Tylenol levels and explained that there were two possible scenarios that could have occurred; either R1 ingested multiple Tylenol pills over multiple days or R1 had a "massive overdose of Tylenol more than 24 hours ago". R1’s medication log was obtained from Walnut House for the month of May 2020. Tylenol was listed as a PRN medication, and the log was not marked on any days for the month of May. It is unclear how resident obtained a large quantity and had an overdose of Tylenol. Resident’s physician report dated 2/20/2019 documents that resident is “unable to administer own prescription medications and is unable to administer own PRN medication”. Additionally, PRN Medication Statement dated 4/19/2019 indicates that resident is “unable to determine his/her own need but is able to clearly communicate his/her symptoms for a non-prescription PRN medication(s)”.

Based on information obtained, the department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.