Complaint Investigation Report

Interview with doctor overseeing R1s care revealed that due to R1s medical diagnosis and medical history they are unable to confirm that R1s death was a result of medication mismanagement. The medication that was not administered for nine days is prescribed to reduce the risk of blood clot; however, that risk does not completely go away by taking the medication. The death certificate was obtained and did not reveal evidence to support R1s death was a result of medication mismanagement.

Although this allegation may be true, based upon the statements made, documents reviewed, as well as site visit observations, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED .

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents.