Complaint Investigation Report

Once S1 realized his error, he reported to front desk after 3-5 minutes. The Licensed Vocational Nurse (S3) responded to monitor R1. Although other measures were attempted to raise R1’s blood pressure, S3 knew it would not drastically help. Further, S3 said she knew R1’s blood pressure would significantly drop and R1’s condition would decline. However, the advice from another nurse (S4) was for S3 to continue monitoring R1 and to call an ambulance only when R1 began showing signs of decline.

The preponderance of evidence standard has been met; therefore, the above allegation(s) were found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.