Complaint Investigation Report

On 09/22/2022 Licensing Program Analyst (LPA) Alberto Lopez conducted a Health and Safety check visit in response to the above allegations. The purpose of the visit was explained to Mary Anne Nacua, Administrator

The investigation consisted of: A physical tour of the facility. No staff or residents were interviewed. Resident (R1's), and (R2’s) file documents Identification and Emergency Information, Physician's Reports, Centrally Stored Medication Record/Medication Administration Records (Aug. 2022- Sep. 2022), and incident reports dated 9/03/22, Personnel Report, and Register of Facility Residents were obtained. No health and safety concerns were observed.

Allegation: Staff did not seek medical attention to client in a timely manner. It is alleged that C1 was in distress and having difficulty breathing and staff did not call 911 immediately or perform CPR.

LPA interviewed four (4) staff and four (3) of four (4) staff admitted to LPA that they didn’t call 911 when they should have. One (1) staff was out of the country at the time of incident and could not comment.

According to review of documents, interviews with witnesses and staff statements. on 09/03/2022 at approximately 4:10 PM, C1 had just finished C1 afternoon snack of Ensure supplemental drink with milk and followed by water. Shortly after finishing the water, C1 started gasping, and C1 skin turned pale and lips bluish. The facility staff caregiver (S4) assisting C1 requested help from another caregiver (S3). Caregiver S3 called the facility Administrator instead of calling 911, who upon arrival at the facility, observed C1 respiratory status and called 911. EMS records show that fire department arrived at facility first at 4:24pm, followed by the paramedics at 4:28pm. Paramedics transported C1 to San Dimas Hospital for further evaluation and arrived at 4:42pm. At approximately 7:57PM, hospital notes indicated a Code Blue. Client was not able to be revived and passed away at 8:16PM. From the time that C1 went into distress at approximately 4:10pm until the paramedics arrived at 4:28pm, no facility staff performed CPR on C1. Evidence shows that the S3 and S4 failed to immediately call 911 when C1 went into distress because according to staff, they panicked and were nervous and instead called Administrator (S1). Administrator did not call or instructed her staff to call 911 when staff called her and informed her that C1 was gasping for air and turning “bluish”. It was only after Administrator arrived at facility, that she called 911. Evidence shows that staff did not seek medical attention for resident in a timely manner when they noticed C1 having a change of condition.

Based on department interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 1 is being cited on the attached LIC 9099D .