complaint·September 25, 2024

To investigate the allegations, on 03/12/24, Investigator Sandoval requested and reviewed R1’s medical and hospice records and interviewed facility staff members, residents and other witnesses, including police officers from the Burbank Police Department. The review of the hospice records revealed Resident #1 (R1) had a DNR on file. On 01/29/2024 at approximately 7:20a.m., hospice staff attended the facility after being informed of a change in R1’s condition and confirmed R1 had expired. The interviews of facility staff revealed at approximately 6:45a.m., staff reportedly discovered R1 unresponsive (not breathing or with no pulse). Staff #1 (S1) indicated the hospice nurse was immediately notified and several attempts were made to inform the responsible party. The interview of responsible party confirmed that on 01/29/2024 they had several missed calls (commencing at approximately 7:00a.m. hours) from the facility. Responsible party indicated when they called the facility back, they were informed R1 had passed away. The interview of Burbank Police Department Detective revealed the incident was not assigned for further investigation as the decedent was on hospice and there was no evidence of foul play observed by the responding officers. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff did not keep accurate records. It was alleged that there was conflicting documentation at the facility regarding the resident. To investigate the allegation, LPA requested pertinent documents at 12:45p.m., and interviewed three (03) staff between 1:00p.m. to 02:40p.m. A review of the facility records clearly shows that the Physician Orders for Life-Sustaining Treatment have different dates on both documents. The Attempt Resuscitation was signed 08/20/2020 and the Do No Resuscitate was signed on 12/22/2022. LPA did not find any documentation in the resident’s file that contradicted these orders. During interviews with staff, all staff stated that resident had an Attempt Resuscitation order and that it was changed to Do No Resuscitate. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of report was issued.