Complaint Investigation Report

did not see R1 at 4:00PM because S1 usually gave R1 their 4:00PM medication at 8:00PM. Records also indicated an outside source asked S1 to check on R1 sometime between 6:00PM and 7:00PM. At that time, S1 did not check on R1. Outside source called a second time, around 7:10PM, prompting S1 to check on R1 and finding them unresponsive. Facility self-reported that paramedics were called immediately, and responsible party was notified. On September 15, 2023, S1 was terminated by facility.

Based on the evidence obtained during the complaint investigation, the allegations that resident was left unattended for extended period of time resulting in resident's hospitalization is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with ED. An exit interview was conducted with ED; a copy of this report and Licensee's Rights (LIC9058) were provided.