Complaint Investigation Report

R1 was found by facility staff to be having an alleged seizure and a large piece of food was removed by facility staff during a finger sweep of R1’s mouth. R1 was transported to a local hospital where R1 later passed away. A review of coroner’s report and death certificate revealed R1’s cause of death was anoxic brain injury due to food bolus obstruction of the upper airway.

Based on interviews and record reviews, the department has determined that facility staff did not provide necessary and timely care and supervision as a safety measure for R1 after R1 entered the bathroom being observed by staff to be coughing with mucus and saliva exiting through R1’s mouth. As a result, this allegation is SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 is assessed in addition to the citation issued. This incident is currently under review and a future civil penalty may apply based on 1548(e)(1) H&S. Failure to correct the deficiencies may also result in civil penalties. An exit interview was conducted with Kimberly Camello and a copy of this report was left with Kimberly. Appeal rights provided.