complaint·April 23, 2024

Staff did not give paramedics the residents emergency paperwork - SUBSTANTIATED It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident. This placed the resident in danger due to unknown code status, unknown health history and unknown drug allergies. LPA reviewed Admission agreement for Resident 1 (R1) that shows and admission date to the facility of 01/10/2024. LPA also reviewed paperwork from hospital dated 02/04/2024 which states: Patient presents to the hospital from the assisted care facility and states that his name is R1. However we do not have a reliable birthday, social security number, or other identifying information. He is being admitted as a John Doe at this point. PAST MEDICAL HISTORY unable to obtain. Medical history is also unknown secondary to patient's severe dementia as well as any sort of specific identifying paperwork. Staff interviews confirmed that staff normally have access to the resident’s emergency packet in a file cabinet and on the facility’s computer database. There was no record for R1 in the file cabinet and when staff attempted to access the record on the computer for R1 it was not in the system and they were unable to provide EMS with R1’s record as a result. COO stated that all resident charts are downloaded into the facility’s system. When staff call 911 they click “Emergency Packet” and all documents that need to go to the hospital are right there. The resident’s packet should have been entered into the system within 24 hours of admission but the packet for this resident was not downloaded into the facility’s system. COO stated that the Resident Care Coordinator contacted the social worker at the hospital who confirmed they had all of the information within 1 hour. It was determined that the emergency packet for Resident 1 was not available to be presented to EMS personnel as required. This allegation is substantiated. 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. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to COO Diania Bingham. Staff are not trained properly on emergency procedures - UNSUBSTANTIATED It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident. COO stated that staff are trained on the procedure to follow when EMS arrives at the facility to transport a resident. It was determined that staff are trained on emergency procedures. This incident occurred due to staff not having access to R1’s records. This allegation is unsubstantiated.