Complaint Investigation Report

The hospital was unaware C1 was taking lithium or that C1’s physician ordered C1’s lithium levels to be checked with a blood test. Facility staff did not ensure emergency medical personnel and hospital personnel had accurate information about C1, including current medications. Facility staff also did not follow physician’s order and ensure C1 had blood work done to ensure C1 had a therapeutic level of the medication and avoid toxicity. C1 was hospitalized on 5/20/21 related to lithium toxicity and acute organ failure. Tri-Counties’ report was received and signed by Administrator Charlotte Acosta Hill on 8/26/21. The above allegation is deemed to be substantiated at this time. Exit interview conducted. Citation issued on 9099-D. Appeal rights emailed. Report emailed to Administrator.