Complaint Investigation Report

R1 was admitted to the facility on 12/26/2023 on hospice care with Hope Hospice. R1 was recertified for hospice on 12/6/2023 with life expectancy of six months or less due to terminal diagnosis and co-morbidities. Physicians Orders for Life-Sustaining Treatment (POLST) dated 4/17/2023 was marked as do not resuscitate (DNR) by W1 and hospice care plan dated 12/26/2023 has advanced directives marked as DNR, no tube feeding, no transfer to acute hospital, and no lab work or x-rays without Hope hospice approval.

On 2/18/2024 unusual incident report indicated R1 was transferred from the facility to San Ramon Regional Medical Center via paramedics for agitation and restlessness. Facility staff S1 contacted Hope Hospice to inform of transfer despite staff relaying that R1 was on hospice. Hospice witness W2, contacted the attending physician and R1 was transferred back to the facility. R1 passed away on 2/23/2024.

The Department obtained certificate of death from Contra Costa County for R1 listing the immediate cause of death as cardiopulmonary arrest and underlying causes protein calorie malnutrition, failure to thrive, and Alzheimer’s dementia. Other significant conditions that contributed to R1’s death were listed as colon cancer with colostomy and atrial fibrillation. There are no questionable circumstances surrounding R1’s death.

This agency has investigated the complaint alleging Questionable Death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.