Complaint Investigation Report

Interview with staff (S1) indicated that R1 is not really using their oxygen and only uses it if staff observe R1 is out of breath. Interview with staff (S3) indicated that R1 uses oxygen only when they walk around the facility, but most of the time they don't use it and don't need it. Interview with staff (S4) indicated that they were told that R1 didn't need their oxygen and R1 only uses their oxygen sporadically when they are walking.

LPA reviewed R1's Physician's Report for RCFE (LIC 602A) dated 7/18/2023, which indicates that R1 has a diagnosis of Chronic Respiratory Failure and Hypoxia as of 5/2022. LPA reviewed Doctor's Order Sheet for R1's oxygen dated 10/20/2023, which states "PRN use of Oxygen when active or ambulating. Staff is to help patient with use of oxygen when needed."

During visit conducted on 1/10/2024, LPA observed R1 in the activity room without their oxygen with them. LPA observed R1's oxygen in their apartment while R1 was in the activity room and not in their apartment.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.