Complaint Investigation Report

Administrator was interviewed and stated that she was notified the morning of 04/29/2023 that an assistant administrator was enroute to the facility to transport the resident (R1) to the hospital because it was reported that R1 was “not acting right.” Staff told Administrator that R1 had “thrown up a little,” was “unusually bloated,” running a fever, and not wanting to eat. Administrator confirmed that she instructed staff not to take the resident to the hospital and to provide a laxative first, as was the resident constipation protocol. Administrator confirmed that she did not respond to the facility in person to assess R1, but stated that staff, “did not tell me anything that seemed like he needed to go.” However, Administrator admitted that it was not common for R1 to throw up or not want to eat. The administrator waited approximately 24 hours before seeking medical treatment for the resident.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D.

As a result of the resident’s death, the violation warrants an immediate civil penalty in the amount of $500, which is being issued. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.

Exit interview held, copy of Appeal Rights provided.