Complaint Investigation Report

Allegation #1: Staff did not assist the resident with obtaining medical care.

Allegation #3: Staff did not monitor resident for change in condition.

The details of this complaint alleged that resident #1 (R1) was not assisted with medical care. The complainant reported that facility staff failed to obtain medical care for (R1) when it was required. On 11/06/23, according to the complainant, (R1) was constipated for three to four days and did not dispatch Emergency Medical Services (EMS) for (R1) to be medically assessed at a local hospital. The complainant reported that the facility staff is not cognizant of (R1’s) change in condition.

On 01/30/24 between 9:20 am – 9:45 am, the Department interviewed Administrator #1 (A1) Yolanda Bernardo. (A1) expressed (R1) was admitted on 10/19/23 at the facility and was only under their care for (18) days. (R1) lived in a private home and was cared for by family members before entering A Paradise Elderly Home.

On 11/06/23 (R1) was taken to Kaiser Permanente South Bay Medical Hospital for constipation. (A1) recalled while (R1) was visited by family members on 11/06/23, there was a concern for (R1's) medical attention. (R1) had not had the usual bowel movement for a couple of days. (A1) claimed that (R1) is on pro re nata (PRN) prescription for Miralax for constipation. (A1) asserted since (R1’s) admittance (R1) was having normal bowel movements five to six times daily. In accordance with the Medication Administration Record (dated: November 2023), (R1) was given (1) capful of Miralax mixed with 6oz of water each day between 11/01/23 and 11/06/23. (A1) declared that (R1) continued to have bowel movements from 11/01/23 through 11/06/23, but it was limited to a small amount of three times daily and not the usual five or six times a day. (A1) refuted the allegation the staff did not fail to seek medical treatment for (R1). (A1) argued (R1) was observed daily for vital signs and did not experience general weakness on 11/06/23. (A1) reasoned that (A1) did not contact (EMS) due to (R1) having only a limited amount of bowel activity. (A1) described (R1) was having bowel activity daily and (R1's) stool was normal. (A1) felt that the situation was not life-threatening and thus did not contact (EMS). (A1) stated it was the family member of (R1) who voluntarily called 911 for (EMS) service to transport (R1) to Kaiser Permanente Hospital. (A1) reported the incident on a Special Incident Report LIC 624 (dated: 11/08/23) to Community Care Licensing (CCL) that (R1) was hospitalized with family who ordered transport via (EMS) on 11/06/23.