Complaint Investigation Report

Based on information gathered, it was revealed that on 12/21/2019, Resident 1 (R1) was transported to the Emergency Room (ER) due to seizure activity that began at 1:08 a.m. At 1:15 a.m., R1 began to have to a series of back to back seizures each lasting 3-5 seconds. Records reviewed reflected that R1 had approximately ten (10) total seizures. S1 contacted facility administrator at 7:00 a.m. at which time the administrator instructed S1 to contact 9-1-1. Interviews conducted and records reviewed further reflected that, R1 has a Restricted Health Condition Care Plan (RHCCP), which states, “Administer 5-10 Liters/Minute oxygen via Adult Medium Mask as needed when having a seizure and call 9-1-1.” Based on interviews S1 did not administer oxygen to R1 as indicated physicians’ orders listed on RHCCP, and Medication Administration Record (MAR). Additionally, it was revealed that Emergency Services was contacted at 7:45 a.m. and paramedics did not arrive until 8:00 a.m. Based on all information gathered, S1 failed to follow physicians orders and obtain timely medical attention for R1; therefore, the above allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, appeal rights discussed, and a copy of this report issued.