Complaint Investigation Report

Regarding the allegation: Due to lack of supervision, resident attained unsecured medications, resulting in hospitalization

It was alleged that Resident #1 (R1) attained and ingested unsecured medications, resulting in hospitalization. A review of hospital records from September 2021 – December 2021 did not reveal instances where R1 was admitted to the hospital due to a medication error. A review of hospital notes revealed that R1 was admitted to the hospital for the following reasons: on 9/15/2021 due to a fall and associated pain as a result of the fall; on 9/16/2021 due to a fall due to increased weakness; on 11/07/2021 due to a choking incident in which R1 was placed on aspiration precautions thereafter and diagnosed with aspiration pneumonia; on 11/15/2021 due to a fall and lacerations; on 12/12/2021 due to a fall, and on 12/22/2021 due to slurred speech and a fall. On 12/22/2021, R1 was also noted to have had a stroke. R1 thereafter was admitted to hospice on

Interviews with staff and a review of submitted incident reports did not validate claims that a medication cart was left unlocked. Staff denied claims that R1, or any resident for that matter, gained access to unsecured medications. In addition, an interview with a family member for R1 denied claims that such an incident took place. As previously stated, a review of hospital records did not indicate that R1 ingested medications which aided in the reason for hospitalization. A review of hospice notes did not document an incident in which R1 had to be evaluated due to a possible medication error. Staff interviews revealed that R1 was very complaint with their medication regime but denied claims that there was ever a medication error while assisting R1 with the self-administration of medication.

Based on the investigation, there is insufficient evidence to support the claim that due to lack of supervision, resident attained unsecured medications, resulting in hospitalization. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Questionable Death

It was alleged that R1 was hospitalized due to ingesting unsecured medications, which resulted in R1’s death. A review of hospital records from September 2021 – December 2021 did not reveal instances where R1 was admitted to the hospital due to a medication error. An interview with R1’s family member noted that prior to being admitted to the facility in August 2021, R1 would often call 9-1-1 due to perceived breathing issues and was highly concerned for their health.