Facility Evaluation Report

On 12/27/2023 LPA Tryon visited the home to do a case management. LPA was visiting to look into the death of a resident in November. The resident had not been eating since the beginning of COVID. The doctor had prescribed Ensure, which he had been using over the past 2 years. He has been seen regularly by his doctor, was taking his medication, and had been doing okay.

On 11/8/23 he was not feeling well, was restless, and the home called to get a doctor appointment at UC Davis Medical Office for him. He was seen by the doctor, x-rays were done and the doctor prescribed an antibiotic, for general infections such as UTI or pneumonia, and the resident had taken one dose around 5:30 p.m. Staff had checked on him several times, and found him non-responsive at 9:00 p.m. Staff called 911 and attempted CPR and emergency personnel responded within a few minutes, but he was already deceased. Placer County Sheriff did respond, and then resident was taken for autopsy. The family has told the licensee that the resident had pneumonia; but the doctor had not told this to the home.

LPA has requested copies of Medical Records, IPP, care notes, etc. The home agreed to scan and email files to LPA.

At this time it appears that the home had been following up with ongoing medical care for the resident, following doctor orders, etc. It had been noticed that the resident was acting a little differently a day before, and the home had taken him for a doctor appointment, he had been prescribed an antibiotic, and the home had followed the doctor order. When the resident was found the staff called 911 and attempted CPR as per 911 direction. It appears the home acted appropriately.

LPA will forward information to LPM for review and any follow-up.