Complaint Investigation Report

Review of order confirmed that resident was to receive "continuous" oxygen as of 9/16/2023 but prior to that it was on an "as needed" basis. Information received during interviews was conflicting on whether or not the oxygen was turned off. Per Licensee, once the physician's order changed from "as needed" to "continuous", the oxygen machine was not turned off for any reason.

A finding that the complaint allegations, Staff neglect caused resident's death and Staff failed to administer resident's oxygen per physicians orders were unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.