Complaint Investigation Report

The Final Autopsy Report for resident (R1) indicated that the diagnoses are as follows: edema, electrical cardiac event, and severe emphysema with organizing bronchopneumonia. The Sacramento County Coroner Report indicated that the cause of death was determined to be Citalopram and Memantine Toxicity, as well as hypertension cardiovascular disease and obesity. The report also indicated that “it is unclear how the toxicity occurred. The decedent’s medications were reportedly controlled by the care facility. There were no reports of suicidal ideations. No suspicious circumstances were found. Based on the circumstances and cause of death, the manner will be listed as Undetermined”. The Toxicology Report indicated that R1 had 620 ng/ml of Citalopram/Escitalopram and 380 ng/ml of Memantine. Interview with Sacramento County Coroner’s Office representative indicated that they did not know if the medication toxicity was due to an overdose or R1’s poor metabolism. Interview indicated that R1’s age could have played a role in their body’s ability to metabolize medication. They also noted that R1 had hypertension and obesity, which increased the risk of having a sudden cardiac arrest. Facility staff did not report any changes in R1’s baseline leading to their death. Staff interviews indicated that R1 did not have a history of pocketing medications, and there were no indications of R1 entering the locked medication room and taking medications.

Based on documentation obtained and interviews conducted, 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. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.