Incident investigation·July 25, 2022

This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported death report received in the Orange County Regional Office (OCRO) on 06/28/22 regarding Resident #1 (R1). LPA met with Administrator (AD) Rachelle Reyes and discussed the purpose of the inspection. The death report (with additional details and clarification from today’s interviews) stated that on 06/27/22 at 4:20 PM, a caregiver observed R1 in bed complaining of not feeling well and called Staff #1(S1) and Staff #2 (S2). S1 and S2 checked R1 and observed R1 complaining of body aches and spitting up small amounts of saliva. R1 was laid back on the bed and S1 and S2 went to go get R1’s medication. At 4:35 PM, Staff #3 (S3) checked on R1, found R1 on the floor, and called S1. S1 assessed R1 and noted R1 was unresponsive and pale. Facility staff called 911. S1 performed CPR until paramedics arrived and the paramedics continued CPR. The police also arrived at around the same time as the paramedics. R1 was pronounced dead at 5:08 PM by the paramedics. During today’s inspection, LPA interviewed AD and staff and requested copies of R1’s Resident File, Medical File, Charting Records, and any other pertinent records. AD agreed to email these documents to LPA by COB 7/26/22. Staff interviewed stated R1 was left alone after being laid back on the bed because, other than complaining about pain, R1 did not appear to be in a medical emergency and staff focused on getting R1 their medications. Staff interviewed also stated that R1 had not recently had any changes in condition, changes in medication, or new symptoms or complaints and that R1’s passing was unexpected as R1 had been doing well and was physically strong leading up to the incident. Staff interviewed stated that it was possible that S3 was also the original caregiver who observed R1 at 4:20 PM. AD will confirm whether or not that is true. Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.