Complaint Investigation Report

Allegation: Staff did not seek timely medical attention for a client. It is alleged that resident (R1) was constipated for at least two weeks prior to November 1, 2025 with visible stomach distention despite using laxatives. It was reported that staff did not take the resident to see a doctor until their prescheduled follow-up CT scan results doctor's visit on October 28, 2025. Resident interviews revealed that R1 complained about stomach pain 5-6 days prior to emergency incident. Staff stated that R1 has history of somatic complaints and that the resident likes medical attention. Staff stated that R1 had a CT scan of abdomen/pelvis on September 22, 2025. The resident saw a physician assistant on October 28, 2025 who prescribed Bisacodyl EC 5 MG Morning and afternoon, and Constulose 10 mg morning and bedtime. The facility received the bubble pack medications on October 29, 2025, but did not administer the medications until November 1, 2025. Based on interviews and record review, the findings indicate staff were aware R1 had stomach pain/discomfort days prior and noticed loss of appetite, but delayed medical attention addressing R1's bowel/stomach issues until the pre-scheduled visit on October 28, 2025 to obtain CT scan results. Staff had knowledge that the resident was constipated and did not have any constipation medications. Despite observing R1 unwell on October 31, 2025 staff did not transport the resident to urgent and/or emergency care. Therefore, there is sufficient information to support the allegation.

Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Pursuant to Title 22, California Code of Regulations, a deficiency was cited.

An exit interview conducted, copy of the report and appeal rights was provided to House Manager Hedika Herrera.