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32 | Pg. 3
Between 6:00 p.m. and 6:39 p.m. R1 started experiencing distress again (gurgling on their own saliva secretion). At some point during this time frame, the on-call nurse directed the facility staff (S1) to clear R1’s throat with sponges and to give R1 liquid Ativan (0.25 ml). Per R1’s representative, they watched “S1 clear out all this goo out of R1’s mouth with three different wet mouth sponges while R1 struggled in discomfort”. S1 cleared R1’s throat with at least three swab sponges and administered the liquid Ativan and left the room. S1 then tells R1’s representative, “to call hospice to tell them to send a nurse to clear out the ‘liquid’ from R1’s throat with a suction machine, the facility has the machine at the facility, but staff are not allowed to use it”. Per R1’s representative, a couple of minutes later, R1 started to throw up liquid, and was pronounced deceased.
LPA Urena interviewed the staff (S1) about administering the liquid Ativan to R1 and S1 stated that they gave the medication to R1’s representative in an oral syringe to give to R1. Furthermore, S1 stated that they did not remember much about the incident, since it happened a year ago. LPA Urena interviewed staff 2 (S2) about the liquid Ativan, S2 stated that they prepared the oral syringe with the liquid Ativan, and they gave it to S1, but because they were not in the room, they are not sure who actually administered the medication to R1. On 04/25/2025, LPA Urena reached out to the Hospice agency’s nurse in charge and asked about the facility’s staff diligence in obtaining assistance for R1, and the Hospice nurse stated that the staff at the facility followed all instructions given to them by the hospice staff, and provided oral suction as instructed by hospice staff. Furthermore, R1 has a DNR/Polst and at no time did family requested for 911 to be called.
Based on the information obtained through interviews and record review, R1 was experiencing distress due to pain and choking on their own saliva. Although S1, cleared R1’s throat with wet sponges and administered the liquid Ativan (0.25 ml) minutes before R1 was pronounced deceased, there is not sufficient evidence to prove that the medication or the clearing of the throat with wet sponges was the cause of R1’s death. R1 was receiving hospice care due to terminal disease. Furthermore, no autopsy was performed, and the Death Certificate lists the immediate cause of death as Cardiopulmonary Arrest, and to Chronic Kidney Decease. Although the allegation may have happened or is valid, based on the interviews, and record review; there is not sufficient evidence to prove the alleged violation did or did not occur Therefore, the allegation is deemed Unsubstantiated at this time.
Exit interview was conducted. A copy of the report was issued. |