Complaint Investigation Report

Allegation: Resident did not get medical attention in a timely manner

Based on interviews and record reviews, the facility did not seek medical attention in a timely manner for resident (R1). Despite home health nurse’s recommendation on 01/14/22 to immediately transport resident (R1) to the hospital due to visual signs of R1’s altered baseline/acute changes in mental status/suspected fever (hot to the touch) and Hypoxia (low blood oxygen level). Both authorized representative (POA) and administrator refused to transport R1 to the hospital on 01/14/22. Administrator stated to investigator that R1 was just “tired and dehydrated”. R1 was finally transported to the hospital on 01/18/22 where he was admitted and diagnosed with urinary tract infection and sacral wounds. The preponderance of evidence has been met. Thus, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date 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.