Complaint·November 16, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not present the residents’ advance directive form to the responding emergency medical personnel. The complaint alleges that the staff failed to provide Resident #1's (R1) directive form to the emergency medical personnel. Reports indicate that (R1) experienced chest pains on October 6, 2025, and was transported to Cedar Sinai by Emergency Medical Technicians (EMT) without a Physician's Orders for Life-Sustaining Treatment (POLST) form. As a result, because no (POLST) form to indicate "Do Not Resuscitate," (R1) underwent repeated cardiac diagnostic testing over several days. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members were able to validate Resident #1 (R1) was transported to Cedar Sinai without a (POLST) or an Advance Directive form was provided to the (EMT). (S1) admitted to having failed to provide a (POLST) form when presented with a copy. (S1) explained that the documents given to the (EMT) included only a Face Sheet Emergency Information and a Verification of Medication Order form, which only listed medications (dated 07/08/24). (S1) understood that it was an unintentional mistake, given the urgency of the situation. In that moment, (S1) genuinely believed that (R1) was experiencing cardiac arrest and felt it was crucial to get (R1) the immediate medical attention needed. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed that (R1) left the facility and was transported by (EMT) to the hospital. However, (R1) does not remember the details of that incident. (R1) recalled experiencing deep, sharp chest pains, and (S1) took the necessary steps to ensure immediate medical attention was provided. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents reported being hospitalized, and hospital staff received the necessary documentation to treat them properly. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 02/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). (Evaluation Report continues LIC 9099-C) Further review of the Physician Orders for Life-sustaining Treatment (POLST) (dated 02/05/25) indicate in section A Cardiopulmonary Resuscitation (CPR) box was checked off - Do Not Attempt Resuscitation/DNR (allow Natural Death) was selected. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Allegation #2: Staff did not follow resident’s hospice care plan. The complaint alleges that the staff failed to follow Resident # 1’s (R1) hospice care plan. Reports claims that (R1) Resident is enrolled in hospice and that hospice protocol requires that hospice be notified as a part of the decision to seek medical intervention. Further reports stated that facility staff contacted hospice after the resident was transported to Cedars Sinai Hospital on October 6, 2025. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members confirmed that Resident #1 (R1) was transported to Cedar Sinai Hospital. Comfort Hospice Care was contacted after the fact, once (R1) was already being transported by Emergency Medical Technician services (EMT). Staff member (S1) was responsible for the emergency incident involving (R1), who was claimed to have failed to adhere to hospice care protocols by not contacting Comfort Hospice Care before calling 9-1-1. (S1) believed (R1) was in cardiac arrest and felt it was vital to get immediate medical help, unintentionally bypassing hospice protocols. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) confirmed to be receiving hospice care when hospitalized. Unfortunately, (R1) does not have any recollection of the events from that day. (R1's) hospitalization was due to severe chest pains, and (R1) can only remember the intensity of the discomfort (R1) experienced. (S1) was there to ensure that (R1) received immediate medical attention during this difficult time. On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot support this claim. All residents had no issues or concerns about this matter, as the staff followed their care plans accordingly. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). (W1) confirmed that the facility staff failed to adhere to the care plan. (Evaluation Report continues LIC 9099-C) The facility is instructed to contact the hospice agency first, rather than calling 9-1-1, in the event of a medical emergency or death. According to (W1), Comfort Hospice Care was notified only after (R1) was already admitted to the Emergency Department. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 002/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). Further review of Comfort Hospice Plan of Care (dated 03/2024) revealed that hospice service “may require procedures performed in a hospital outpatient setting, and that Comfort Hospice Care will arrange for these services as needed, as indicated on the plan of care”. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED. An exit interview was conducted with Robin Culver, and copies of the reports were provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff mismanaged resident’s medication. Allegation#4: Staff did not properly report the resident’s incident to the resident’s authorized representative. The complaint alleges that staff mishandled Resident #1's (R1) medication and failed to inform (R1’s) authorized representative about an incident involving (R1). Reports indicate that staff administered “Nitroglycerin”, prescribed by (R1's) cardiologist, before (R1’s) hospice designation. Incident report show (R1's) initial vital signs recorded a blood pressure of 95/55, but this was omitted from the initial incident report; only the readings taken after administering “Nitroglycerin” were noted. After receiving “Nitroglycerin” twice, (R1's) blood pressure dropped to 78/53, resulting in a hypertensive condition, and (R1) was sent to the hospital. On November 6, 2025, between 09:30 AM and 11:15 AM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) of the three (3) staff members disputed both allegations. They confirmed that Resident #1 (R1) experienced chest pains that felt like stabbing sensations in the chest and radiated around the neck at a pain level of 10 out of 10. (R1) was given "Nitroglycerin" as a PRN medication prescribed by (R1's) primary physician from Comfort Hospice Care. The staff also stated that the information provided in the incident report to (R1's) authorized representative was accurate. (S1) indicated that they followed (R1's) medication plan by administering "Nitroglycerin" in an emergency setting to relieve chest pain and improve circulation. (S1) reported that when "Nitroglycerin" was given, (R1's) blood pressure was measured, with the systolic blood pressure (SBP) exceeding 90 mmHg. (S1) stated that the incident report submitted to the authorized representative and Community Licensing is accurate, and that no amendments have been made to the reports. On November 6, 2025, between 11:16 AM and 11:31 AM, the Department interviewed resident member identified as Resident #1 (R1). (R1) reported experiencing chest pains that radiated in (R1's) back and neck. Although (R1) does not remember much about the incident, (R1) recalls being assisted by (S1), who provided pain medication that did not ease (R1's) symptoms. Despite that, (R1) was grateful that (S1) was there to take urgent measures and get medical assistance. (Evaluation Report continues LIC 9099-C) On November 6, 2025, between 11:32 AM and 01:30 PM, the Department interviewed resident members identified as Resident #2 through Resident #7 (R2-R7). Six (6) out of six (6) resident members cannot validate these claims. (R2-R7) stated medications have been handled appropriately, and there have been no reports of incorrect or unreported medication to their authorized representatives. On November 14, 2025, between 04:30 PM and 04:47 PM, the Department interviewed staff member of Comfort Hospice Care identified as Witness #1 (W1). According to (W1), Nitroglycerin is included in (R1's) prescribed medications. Comfort Hospice Care prescribes it as needed (PRN), starting July 8, 2024, for use at the first sign of an attack. It can be repeated every 5 minutes up to 3 times in 24 hours, with a maximum of 3 tablets per dose. (W1) indicated that (S1) took the appropriate actions by administering Nitroglycerin to (R1), who was experiencing chest pain attacks, on October 6, 2025. A review of (R1’s) Face Sheet and Emergency Info (dated 10/07/25 and 10/16/25), Service Plan (dated 02/05/25 and 06/29/25), Resident Assessment (dated 06/29 25), Physician’s Report LIC 624A (dated 02/24/25), and Unusual Incident Report LIC 624 (dated 10/07/25). Further review of Comfort Hospice Plan of Care (dated 03/2024), Cedars Sinai Medical Records (dated 10/10/25), End of Shift Report (dated 10/06/25 – 10/14/25) and Physician Orders for Life-Sustaining Treatment (POLST) (dated 02/05/25). Further review of Medication Administration Record (dated 10/1/25 -10/31/25) verified that Nitroglycerin is prescribed by Comfort Hospice Care. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated . An exit interview was conducted with Robin Culver, and copies of the reports were provided.