Complaint Investigation Report

LPA did not observe any immediate health and/or safety concerns during today's visit. LPA observed a sufficient supply of perishable and non-perishable foods for the clients in care.

LPA requested copy of file of C1 for 11/2021 - 04/2022 and Administrator will send copy to LPA.

LPA Interviewed Five (5) staff (S#1-S#5) and one witness (W1) and attempted to interview four clients(4) (C#1-C#4).

Allegation: Questionable Death. It is alleged that facility failed in their responsibility to provide care and supervision and it led to the death of C1

LPA interviewed five (5) staff and five (5) of five (5) staff denied the allegation. LPA was not able to interview any clients. LPA interviewed one witness from Regional Center Witness #1

According to Department interviews, and records reviewed, client was found by DSP S4 at approximately 6:30 – 6:45AM on 4/23/22. When S4 found C1 unresponsive. S4 noted that client had no pulse on C1 wrist. S4 also noted that C1 chest was not rising, and saliva was coming out of C1 mouth with bubbles. S4 called for S5 to come to room, telling S5 that S4 thought C1 was dead. S5 noticed client was not moving, was pale, yellowish and had saliva coming out of C1 mouth. Neither staff touched client. 911 was called and call did not initially go through. 911 was called again and 911 operator asked S4 if client was responsive. S4 said no. 911 operator asked if S4 could perform CPR. I don’t think so because S4 thought client was “gone”. S4 stated S4 didn’t want to make matters worse. According to S4 911 operator told S4, I understand, wait for paramedics. When paramedics arrived at the facility, they declared client dead.

According to records reviewed, when paramedics arrived, they observed that the client was deceased. Paramedics performed chest compressions. Documents show that C1 had been deceased at least 2 hours prior to arrival of paramedics

The 1:1 staff (S2) who was assigned to supervise resident from 4/22/2022 at 10pm to 4/23/2022 at 6 am failed to monitor resident closely and to seek for help when resident had tonic-clonic seizure, leading to C1 death of Cardiopulmonary arrest. Resident was already deceased before the morning shift arrived on 4/23/2022 at 6:30 am., when they found resident unresponsive with no pulse and rigor mortis was present.

The death of C1 was the result of a tonic-clonic seizure that causes violent muscle contraction and gurgling sounds that should’ve alerted S2, who was the clients 1:1 that night, that C1 was in distress and summoned medical attention immediately for C1. S2 stated S2 did not hear or observed anything during S2 shift. Facility did not provide satisfactory care and supervision to meet C1 needs. There is sufficient evidence to substantiate this allegation.