Complaint Investigation Report

Once again, paramedics were contacted, they attempted to talk to C1, but they were not responding, and they transport them to the hospital for further evaluation. On 2/8/25, C1 passed away while they were hospitalized. Based on records review, C1 was admitted to the facility since May 5, 2001. C1’s weight record logs indicates that C1’s weight was 101 pounds in March 2015, which it was the last weight documented by the facility. C1’s physician report dated 2/13/24 indicates that C1 declined dentures and did not have any teeth. However, there was no indication of special diet. Although, the facility was able to provide LPA with an after-visit summary for C1 dated 2/13/24 where indicates that C1’s weight was 93 pounds and had a follow up appointment within 6 weeks on 3/26/24 for weight check and nutrient supplements follow up appointment. C1’s prescription order confirms that there was a doctor’s order for ensure liquid one bottle orally three times daily. However, it was confirmed by C1’s responsible party that they were fulfilling C1’s prescription order. On 2/26/25, Licensee provided LPA with C1’s death certificate indicating cause of death was due to acute respiration failure with hypoxia as a subsequent underlying cause of death pneumonia. Other conditions that contributed to death were chronic obstructive pulmonary disease, acute kidney injury and septic shock. A finding that the complaint allegation occurs of staff did not ensure a client was properly fed while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.