complaint·January 9, 2025

LIC9099-C Continued... Allegation: Questionable Death Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s medical documents showed that on 01/07/2022, R1’s primary diagnosis was unspecified depressive disorder. On 01/27/2022 R1 had an ER visit at Contra Costa Regional Medical Center for nicotine patch and redness in right ear. On 04/27/2022 Staff (S1) received a radio call approximately 1145-1300 that there was an emergency in R1’s room. S1 stated that they found R1 unresponsive while S2 was performing the Heimlich Maneuver. S1 stated that they began giving Cardiopulmonary Resuscitation (CPR) and dialed 911. S1 stated that Paramedics arrived and continued emergency resuscitation. S1 stated that R1 was admitted at John Muir Medical Center in Walnut Creek, CA. Per review of subject resident’s Needs & Services and interview resident was independent in eating and not a choking risk. Review of documents reports that R1 passed away on 05/04/2022 at 1312. Documents obtained do not suggest R1’s death was a result of neglect or lack of care for suspicious circumstances from facility staff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of questionable death and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of questionable death is unsubstantiated. Exit interview conducted and a copy of this report provided.