Complaint Investigation Report

Allegation #1: Staff did not seek medical attention for resident in a timely manner.

Allegation #2: Staff did not notify Resident's Representative about Resident's change in condition in a timely manner.

The details for this complaint alleged that facility staff did not seek medical attention for resident # (R1) in a timely manner nor did not notify (R1’s) representative about (R1’s) change in condition timely. The complainant reported that staff did not adequately check on (R1) before (R1’s) death on 01/22/22 nor did staff seek medical attention for (R1) when staff observed a change in condition. The complainant did not have further additional details on these matters.

Resident #1 (R1) was admitted at Avenida Villa on 09/18/18 after a discharge from Lomita Acute Center. Upon discharge, (R1) was placed on home health services by Torrance Home Health. (R1) was recertified for home health throughout 2018-2022. (R1) had a change of condition that required a higher level of care and family representatives for (R1) were notified and agreed to admit (R1) for hospice with Providence Trinity Care Hospice effective 01/18/22 up to (R1’s) passing on 01/22/22. (R1) was always under the care of medical professionals with home health and hospice nurses and doctors.

On 08/09/23, the Department received a written Declaration LIC 855 (dated: 08/09/23) from administrator #1 (A1). (A1) claimed that (R1) was under professional supervision and care with nurses and doctors while (R1) was at Avenida Villa. (R1’s) family members were always at the facility during home health and hospice visits with nurses discussing (R1’s) condition. (A1) stated when it came to (R1’s) medical needs it was always taken care of by the home health and hospice medical professionals. (A1) claimed the facility staff were only responsible for (R1’s) non-medical care since the facility is a non-medical care facility.

On 03/22/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#2 (S1-S2) all verified that (R1) was being monitored on 01/22/22 hourly by staff before (R1’s) passing. (A1) and (S1) communicated they checked on (R1) at 7:30 am and 8:00 am on 01/22/22. At 8:00 am (S2) checked (R1’s) blood pressure, pulse, and changed (R1’s) diaper, and applied ointment. (R1) was still conscious at that time. (A1-S2) check on (R1) again at 9:00 am and (R1) was non-responsive. (A1) called the hospice nurse and family to inform them that (R1) was non-responsive. (A1) immediately contacted (R1’s) family representatives of (R1’s) change of condition. A hospice medical professional arrived along with the family representatives at 10:00 am on 01/22/22.

This report serves as an amendment to clarify finding in line #23. It does not supersedes the complaint investigation findings reflected on report created 03/22/24 .