Complaint Investigation Report

The details of the complaint alleged that (R#1) died due to facility staff not following up on their change of condition and not providing CPR when need it.

During the records review gathered by CCLD staff, the department observed that on (R#1)’s physician assessment dated 1/5/23. It states that (R#1) was ambulatory and could bathe, groom, feed, and care for their needs. (R#1)’s medical diagnosis was not related to respiratory comorbidities. In addition, CCLD staff reviewed (R#1)’s discharge papers from Pacific Villa Skill Nursing Home; the discharge papers listed the same medical diagnosis found on their physician’s assessment and did not list any respiratory issues. Moreover, CCLD staff reviewed (R#1)’s death certificate dated 1/25/23; it is listed that the cause of death was cardiac arrest and hypertensive heart disease.

During an interview conducted by CCLD staff with facility administrator (A#1) on 4/22/24, she stated that on 1/8/23, (R#1)’s roommate (R#2) pulled the emergency cord and (S#3) saw the light on the switchboard, then (S#3) called (S#2) that went to check on (R#1) while she contacted the facility nurse (S#1). (S#1) told (S#5) to contact emergency services-911, “All this happened within minutes. When (S#1) checked on (R#1), they had a pulse, and we do not do CPR if residents have a pulse”.

During an interview conducted by CCLD staff with facility nurse (S#1), she stated that she would check on (R#1)’s blood pressure and sugar levels at least once during her shift. In addition, (S#1) stated that on the day of (R#1)’s incident, (R#2) pulled the emergency cord at approximately 18:50 PM hours, (S#1) arrived at approximately 18:55 PM hours to (R#1)’s room where they were laying on the floor unresponsive, (S#1) assessed (R#1)’s vitals and found they had a pulse, (S#1) mentioned per facility policy we do not performed CPR if resident has a pulse. (S#1) positioned (R#1) in a supine position and told (S#3) to call 911; Long Beach Fire Department arrived at the facility at approximately 19:05 PM and performed CPR on (R#1) for approximately 20 minutes before declaring them dead at approximately 19:37 PM.