Complaint Investigation Report

The complaint allegation alleges that due to untrained staff transferring R1 to the hospital for dementia related behavior led to confusion and transfer trauma resulting in R1’s death.

During record review, LPA received and reviewed a copy of the staff Narrative Charting for R1, upon review LPA observed R1 was transferred to UCLA (Westwood) Hospital for a needed mental health evaluation on 04/19/23. Additionally, LPA observed UCLA ER contacted the facility on 04/20/23, to inform them they were transferring R1 to Glendora Hospital for admission. During interviews with W1, LPA was informed R1 was being transferred due to UCLA being at capacity. LPA reviewed the discharge document from Glendora Hospital and observed R1 was treated at Glendora Hospital from 04/20/23 till 04/22/23 due to a neurocognitive disorder. Glendora Hospital then transferred R1 to College Medical Center on 04/22/23 due to R1 requiring additional medical care. LPA reviewed the discharge documents for R1 and observed that R1 was diagnosed with acute hypoxic respiratory failure and found to have a dissection at the distal part of the aortic with an additional diagnosis of pneumonia. R1 received care at College Medical Center till discharged on 04/26/23. During R1’s admission at College Medical Center, the family opted for hospice care and comfort measures only, due to R1s worsening health status. After discharge, R1 was transported back to the facility on 04/26/23. Upon review of R1’s Death Certificate, LPA observed it stated the immediate cause of death to be “Cardiopulmonary Arrest.”