complaint·October 16, 2024

Investigation Revealed the Following: Allegation: Questionable Death. The details of the complaint alleged that (R#1) died due to facility staff not following up on their change of condition and not providing CPR when need it. During the records review gathered by CCLD staff, the department observed that on (R#1)’s physician assessment dated 1/5/23. It states that (R#1) was ambulatory and could bathe, groom, feed, and care for their needs. (R#1)’s medical diagnosis was not related to respiratory comorbidities. In addition, CCLD staff reviewed (R#1)’s discharge papers from Pacific Villa Skill Nursing Home; the discharge papers listed the same medical diagnosis found on their physician’s assessment and did not list any respiratory issues. Moreover, CCLD staff reviewed (R#1)’s death certificate dated 1/25/23; it is listed that the cause of death was cardiac arrest and hypertensive heart disease. During an interview conducted by CCLD staff with facility administrator (A#1) on 4/22/24, she stated that on 1/8/23, (R#1)’s roommate (R#2) pulled the emergency cord and (S#3) saw the light on the switchboard, then (S#3) called (S#2) that went to check on (R#1) while she contacted the facility nurse (S#1). (S#1) told (S#5) to contact emergency services-911, “All this happened within minutes. When (S#1) checked on (R#1), they had a pulse, and we do not do CPR if residents have a pulse”. During an interview conducted by CCLD staff with facility nurse (S#1), she stated that she would check on (R#1)’s blood pressure and sugar levels at least once during her shift. In addition, (S#1) stated that on the day of (R#1)’s incident, (R#2) pulled the emergency cord at approximately 18:50 PM hours, (S#1) arrived at approximately 18:55 PM hours to (R#1)’s room where they were laying on the floor unresponsive, (S#1) assessed (R#1)’s vitals and found they had a pulse, (S#1) mentioned per facility policy we do not performed CPR if resident has a pulse. (S#1) positioned (R#1) in a supine position and told (S#3) to call 911; Long Beach Fire Department arrived at the facility at approximately 19:05 PM and performed CPR on (R#1) for approximately 20 minutes before declaring them dead at approximately 19:37 PM. Evaluation Report continues LIC 9099-C During an interview conducted by CCLD staff with facility staff (S#2), she stated that on the day of (R#1) incident, she was the one that went first to check on them upon arrival (S#2) observed (R#1) lying on their right side on the floors unconscious, (S#2) callout (R#1) by their name but (R#1) failed to responded. At this point, (S#2) checked on (R#1)’s pulse and informed (S#3) to come and assist her with (R#1). (S#3) called facility nurse (S#1) to come and check (R#1) vitals. During an interview conducted by CCLD staff with facility staff (S#3), she stated that the day of (R#1)’s incident, she saw a light turn on the signal switchboard, she contacted (S#2) and told her to go and check on (R#1)’s room, when (S#2) arrived at (R#1)’s room, (S#2) called (S#3) and let her know that (R#1) was on the floor, (S#3) when to assist (S#2) with (R#1) and called facility (S#1) nurse on her way. (S#3) observed (S#1) arrive at (R#1)’s rooms and promptly check on their vitals. (S#1) instructed (S#5) to call 911. (S#3) returned to the office to call 911 and prepared (R#1) needed paperwork for the emergency department. (S#3) stated that the Long Beach Fire Department arrived at the facility at approximately 19:05-19:10 PM, less than 10 minutes after the call. During an interview conducted by CCLD staff with residents in care (R#2-R#5), (4) out of (4) residents stated that facility staff does a good job taking care of them and that they feel “happy” living there. During an interview conducted by CCLD staff with (R#1)’s Primary physician (W#2), he stated that (R#1) did not note any issues with their breathing; he stated that he would rarely receive calls for any issues with them. (W#2) stated that had (R#1) complained about shortness of breath, especially within a month prior to their discharge to Regent Villa, he would have documented this, which he did not, “a sudden death like that is likely due to (R#1)’s diagnosis not related to breathing issues. During an interview conducted by CCLD staff with witness 1 (W#1), they stated that they felt that the staff should have conducted CPR on (R#1) once they found them on the floor instead of waiting until Long Beach Fire Department arrived. Evaluation Report continues LIC 9099-C Allegation: Staff failed to respond to signal system in a timely manner. The details of the complaint alleged that facility staff does not respond to resident’s signal system in a timely manner. During an interview with the administrator (A#1), she stated that it takes the facility staff less than 3 to 2 minutes to assist a resident when they pull the alarm cord. In addition, (A#1) stated that depending on the situation, if a resident needs immediate medical assistance, we call 911, and sometimes the residents pull the cord for non-emergency situations. During an interview with facility staff (S#4-S#6), (3) out of (3) stated that it takes approximately between 3 to 5 minutes to answer the pull alarm cord. During an interview with a resident in care (R#6-R#14), (7) out of (9) stated that they have never used the emergency cords, and (2) out of (9) stated that they have used it once and the time they used it, it took the facility staff less than 3 minutes to assist them. Allegation: Staff are not properly trained in emergency procedures. The details of the complaint alleged that facility staff are not properly trained for emergency procedures. During the records review, department staff observed a list from facility staff showing that all direct care employees have their current CPR training/card. Evaluation Report continues LIC 9099-C During an interview with the administrator (A#1), she stated that facility staff is trained in emergencies. We take CPR training every year or two, and once a month, we discuss it during our monthly staff meetings. In addition, (A#1) stated that the protocol that facility staff follows in an emergency is the following: we call immediate 911, assess the resident if the resident is not responsive, and perform CPR. During an interview with facility staff (S#4-S#6), (3) out of (3) stated that they take their CPR training every year or two. Also, every month, in our staff meeting, we talk about emergency procedures. During an interview with a resident in care (R#6-R#14), (9) out of (9) stated that they feel the facility staff is trained in emergencies. During this investigation, the department did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Jenni Gordon /Administrator.