Complaint Investigation Report

On the allegation of the questionable death of R1, it is the concern of the reporting party that the death of R1 is the result of the staff administering medication and not providing proper suctioning. To investigate the allegation, LPA Urena interviewed staff, administrators and the RP, and conducted record review. The record review revealed that R1 was receiving hospice services at the time of death. The Certificate of Death from the State of California indicates that R1’s immediate cause of death was Cardiopulmonary Arrest and terminal disease and condition (chronic kidney disease and congestive heart failure) resulting in death. No autopsy was conducted after death. Hospice records dated 11/14/2023, revealed that R1 had discontinued all curative treatments and had a terminal prognosis of six (6) months at the time of the report. Records review of the Medication Administration Record (MARS) used by the facility, indicated by the initials on the date of 03/17/2024, that S2 was the facility staff that prepared /administered the liquid Ativan (0.25ml) to R1, and that R1’s Representative administered liquid pain medication (Morphin 0.25ml).

The interview with the RP revealed that on 03/17/2024 at approximately 3:00 p.m., R1’s representative found R1 in their bed in distress. R1’s representative was told by facility staff that R1 was unable to swallow the pain medication, which was due at 2:00 p.m. Facility staff stated to the representative that they were not skilled professionals and consequently could not administer the pain medication. The facility staff provided the pain medication to R1’s representative to administer to R1 at approximately 3:50 p.m. and after the pain medication was administered, R1 appeared to be relaxed. Furthermore, the R1’s representative stated that they were informed that R1 could not swallow and started communication with the hospice nurse in charge to ensure that R1 would continue to receive the pain medication as needed to keep them comfortable. At approximately 5:49 p.m. R1’s representative texted the hospice nurse of R1’s condition, letting them know that R1 is experiencing distress again due to gurgling their own saliva because they cannot swallow. Per R1’s representative, the hospice nurse in charge was out and did not have a reliable cell phone, consequently the hospice nurse in charge referred the representative to the hospice on-call nurse at approximately 6:00p.m.