Complaint Investigation Report

presented in the emergency room (ER) with an “altered mental status, fatigue and generalized weakness…” R1 was diagnosed with sepsis. Interviews with staff noted that R1 would refuse treatment. Facility documentation notes that staff checked on R1 when they observed a change in condition. It was unclear if R1 developing sepsis was due to staff not obtaining timely medical attention or due to R1’s refusal for treatment. Due to these inconsistencies, there was not a preponderance of evidence to substantiate that hospitalization was a result of lack of care and supervision. The allegation was UNSUBSTANTIATED and no deficiencies were cited.

Exit interview was conducted with Executive Director and a copy of this report was provided.