DENVER HOSPICE CARE CENTER, THE

SUMMARY OF FINDINGS:On 8/21/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported the death of a client. The client was found on the floor unresponsive and without any signs of life. The client was on hospice services and the client was not actively passing at the time of this incident. During the course of the investigation the healthcare entity provided the client with dignity after passing, conducted interviews and record review. It was discovered Staff #1 did not conduct a safety check as scheduled, however, this would not have prevented the unwitnessed fall client. Policies were reviewed for falls, safety checks, signage was used and arm bands for better identification of clients at risk for falls. The client had an unwitnessed fall before being found deceased. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 11/11/2025 · released to the public 11/19/2025.

DESCRIPTION OF OCCURRENCE: On 5/9/23, the facility received information regarding an alleged drug diversion and immediate risk of patient safety involving an agency staff member (Certified Nurse Aide – CNA1). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician. Management removed CNA1 from the work schedule and their badge access to the facility was revoked. A nurse checked on the patients and no concerns were identified. An audit occurred of medication records and per the facility; all patients received their prescribed medications. The staffing agency provided screenshots and photos regarding the allegations involving CNA1 for review, which included text messages alleging CNA1 was going to "kill a patient" and photos of CNA1 holding medication vials in a room later identified to be a restroom in the Care Center. Other photos showed CNA1 having other medication vials and needles in their possession at their personal residence. The facility was unable to determine the quantity of medications involved, but some photos showed vials of Pepcid (antacid), Lorazepam (anti-anxiety), Haldol (sedative) and Hydromorphone (narcotic) in CNA1’s possession. Management was unable to determine if the vials were empty or if they contained medications inside. With CNA1’s license type, they should not have access to the medication vials within the facility. All nursing staff was interviewed regarding current medication administration protocols and destruction guidelines. Staff who worked with CNA1 stated s/he would linger in the medication room after requesting pre-medications for a patient prior to providing care. There were also reports of CNA1 routinely volunteering to take out the medication room trash, which contained disposed medication vials. From the findings, the facility discovered staff did not follow security guidelines with the locked medication room or who accessed the area. Nursing staff were not following medication waste and destruction protocols. The facility concluded CNA1 had access to the medication vials and should not have been left alone in the medication room. The allegation of a drug diversion was substantiated. In regards to the patient threat, the actual patient could not be identified and further details were unknown. All current patients were noted to be safe. CNA1’s employment was terminated from the staffing agency and care center. The police and licensing oversight agency was notified regarding the findings from the investigation. Medication rooms were secured, which included limiting badge access to only nurses. Re-education was provided to staff on medication administration policies/protocols and expectations to secure medications. Staff was encouraged to report any observations of behavioral or compliance concerns with other staff. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 3/25/2024 · released to the public 3/25/2024.