Old people die!!
Has anyone ever told you that before? I have heard it over and over again since November. I realize that we are all going to die sooner or later. Does that mean if you die from a medication error or complications from an accidental fall, that it doesn't matter? Beleive me it matters when it is your Mother. It matters to all of her children, grandchildren and great grandchildren, as well as neices, nephews and other family members.
I realize that ther is nothing that can bring her back, or change what happened. Sometimes just knowing what really happened can provide comfort. It's not about blame, or making someone "pay' for your loss. It's about identifying a serious problem, and trying to fix it!
I think the agencies that oversee the care of the elderely, dont follow through. If they did ,someone would have to figure out how to fix the system. No one agency can fix all thats wrong, but someone has to start. It will take all the agencies working together, and enforcing the regulations rather than ignoring them. It would mean following through with the enforcement of the regulations. It would mean actually earning their paychecks. Simply put ,just doing their jobs would start the necessary changes to fix whats wrong.
It's similar to the way they dealt with terrorisim, the F.B.I. the C.I.A. the D.O.D and local and Federal government agencies working together for one goal.
Cooperation  between the NCDHHS, the Board of Nursing, the Medical Board, and local and State agencies,working together without corruption . That would improve the system 100%. Get off your lazy ass and do your job. It's that simple.