Complaint Investigation Report

S2 reported that on 04/26/2025, R1 developed a fever and was treated with Tylenol and a lukewarm shower per on-call instructions. On 04/28/2025 at 8:00 PM, S2 observed R1’s condition worsening. After attempts to contact S1, S2 called on-call and then 911, resulting in R1’s transport to the hospital.

S3 reported that R1 had been ill for several days and became confused on 04/27/2025. On 04/28/2025, most caregivers believed R1 should be transported immediately, but managers declined. After the managers left, S3 noted R1’s condition did not improve, contacted S1 at 10:30 PM, and was advised to move R1 to the television room for comfort. At 11:58 PM, the on-call delivered a thermometer and blood pressure cuff; vitals were normal, but R1’s breathing worsened. At 12:22 AM on 04/29/2025, S3 called 911, and R1 was transported. S4 was the on-call staff and provided additional medical observations of R1. Based on these observations, S4 determined that R1 was not in distress but was experiencing symptoms of illness. Appropriate steps were taken to ensure R1’s well-being, as R1 was observed drinking fluids, eating, and engaging with staff during this time.

While hospitalized, R1 was intubated twice. After the family established Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders, R1 passed away. Based on R1’s medical records, R1 had an extensive medical history that contributed to their decline and the development of aspiration pneumonia. There were numerous unsuccessful attempts to contact the Reporting Party (RP); no additional information was obtained. There was no corroborating information in the medical records to indicate the facility was negligent or had delayed medical care.

The investigation concluded that the allegation was unsubstantiated. A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Valarie Davis, Program Coordinator. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Program Coordinator, and her signature on this report confirms receipt of the Licensee Rights.