Complaint Investigation Report

Investigation Findings: It was reported to the department that staff waited approximately 60 minutes prior to calling 911. S3 stated S3 noticed at 8:30 AM that the bathroom door where R1 was found was locked. S3 returned at 9:30 AM to open and clean the bathroom when S3 found R1 unresponsive and yelled for someone to call 911. S8 stated S3 informed S8 about 9:50 AM that S3 found R1 unresponsive and to call 911. S6 reported hearing S3 call for someone to call for 911 and did so at 8:30 AM. According to the Oakland Fire Department (FD) Incident Report, the FD wasn’t notified of R1’s need for emergency services until approximately 10:21 AM. When asked by the FD why facility staff waited 60 minutes before calling 911, the Med Tech on duty was unable to explain, therefore the allegation is SUBSTANTIATED.

Based interviews conducted during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty.

Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy.

Exit interview conducted, Appeal Rights, and a copy this report provided.