Complaint Investigation Report

One form was blank inside the binder and the completed DNR form was placed on the front sleeve of the binder. An interview with the licensee revealed that during the incident in question staff called the licensee and advised the fire chief wanted to speak with the licensee. The fire chief reported not being able to locate the DNR form. The licensee instructed the fire chief to look in the resident's file.

It was alleged staff did not destroy resident's medication. It was reported to the Department facility staff did not destroy R1 medication, but instead handed R1’s medication to R1’s family, after R1 was deceased. Interviews with internal sources reported staff released R1’s medication to R1’s family after R1’s hospice agency approved for the medication to be released. Additional interviews with internal sources revealed it was not the facility’s protocol to release medication to families, nor the hospice agencies. The facility’s protocol called for two staff to destroy the medication and sign the required destruction form. An interview with R1’s hospice service provider confirmed there was no indication the agency had approved the release of R1’s medication, and it was not common for this agency to retrieve, or destroy medication.

Based on evidence obtained, the allegations were substantiated and cited in an LIC 9099-D form. Plans of Corrections (POCs) were jointly formulated with Licensee Gus Fernandez.

An exit interview was conducted with Gus Fernandez, to whom a copy of this report, LIC 9099-D, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided.