complaint·March 15, 2024

Interviews with three (03) out of three (03) staff and the licensee confirmed that R1 had no signs of infection, sepsis, or any symptoms of illness, no diagnosis of sepsis, and no physician’s order or prescription for antibiotics to address an infection. Interview with S1 at 11:20 a.m. on 03/05/2024 revealed R1 was last hospitalized on 02/12/2024. Record review at 12:00 p.m. on 03/05/2024 revealed R1 was admitted on 02/12/2024 for syncope and returned to the facility on 02/15/2024. R1 returned with two new physician’s orders for eye drops and a medication for heart arrhythmia. S1 confirmed R1 was assisted with all current and new medications. Around 11:00 p.m. on 02/26/2024, S1 and two (02) other staff noticed R1 having difficulty breathing. S1 called 9-1-1 and performed CPR until paramedics arrived. Record review of hospital records revealed R1 was admitted to Kaiser Woodland Hills around 2:30 a.m. on 02/27/2024 with low blood pressure and low blood oxygen levels. R1 was diagnosed with septic shock with pneumonia suspected as the source of the infection. Based on interviews and record review, facility staff followed all physician’s orders and sought medical attention promptly when R1 exhibited distress. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed during this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.