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32 | 03/23/2015. Physicians’ reports in the facility records for R1 were dated as follows: 09/17/2018, 10/09/2019, and 10/07/2020 all completed by R1’s primary treating physician. R1’s physician also examined R1 on the following dates: 10/04/2019, 06/12/2020, 07/16/2020, 10/11/2020 and 11/02/2020. According to R1’s physician, R1 visited his office on 10/04/2019, the other visits occurred at the facility. During the 10/04/2019 visit an electrocardiogram (ECG) was performed as well as a blood draw for lab work. The ECG showed R1 had suffered two prior heart attacks: one significant and one minor. R1 had no recollection of suffering previous cardiac events. R1’s physician stated R1’s lab results showed R1 appeared to be diabetic. R1’s physician explained it is not unusual for a person with diabetes to not feel chest pain; it is known as a silent heart attack. R1’s physician encouraged R1 to eat healthier and exercise. R1 was told to return to the physician’s office after fasting so more blood work could be obtained, and the physician could determine what type of diabetes medications to prescribe. However, R1 never followed through with getting fasting blood work done. R1’s physician stated R1 was capable of following up on medical appointments. R1’s physician was unaware of R1 having any family involved in her medical care. R1’s physician stated the lack of blood work did not cause R1’s death. R1 was taking two blood pressure medications.
Staff who handle making medical appointments did not recall any requests from R1’s physician for fasting blood work. R1’s physician sees several residents who reside at the facility and has an office in a small room on the first floor of the facility. If the physician wants staff to follow up on something like appointments for blood work, the physician notifies one of the medication technicians. However, some of the physician’s patients handle their own follow up medical care needs.
During the time surrounding R1’s death, the facility had an outbreak of COVID-19. R1 had a PCR test done on 12/06/2020 and tested negative for COVID-19.
The death certificate indicated the immediate cause of death was acute myocardial infarction with underlying causes listed as hypertensive arteriosclerotic heart disease, diabetes mellitus, hyperlipidemia, and obesity.
Based on the medical records, staff interviews and an interview with R1’s physician, it does not appear that lack of following through with blood work led to R1’s death. There is insufficient evidence to confirm that R1’s death was due to facility staff neglect; therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.
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