Complaint·December 23, 2021

Based on the investigation completed, there was corroborating evidence to support the allegation that staff neglect resulted in R1’s death. On July 11, 2020, at approximately 3:15pm, R1 was transported by paramedics to the hospital. According to medical records R1’s body temperature was measured at 109.2 degrees F (upon admittance to the hospital. The investigation revealed, according to the National Weather Service, on July 11, 2020 the temperature in the local area was 97 degrees F at 11:53am, 101 degrees F at 12:53pm, 103 F degrees at 1:53pm and 104 degrees F at 2:53pm. Medical records indicate that on July 11, 2020, R1 was diagnosed with heat stroke, dehydration and second and third degree burns to the bilateral upper extremities, bilateral legs, buttocks and lower back area, estimated at 30-40% of R1’s body surface area. An autopsy report cited the cause of death as “Hyperthermia due to environmental heat exposure.” Staff interviews revealed residents are checked on every 1 to 2 hours. Interviews further revealed that R1’s whereabouts were unknown by staff from approximately 12pm to 3pm. A review of a law enforcement report divulged information from medical staff interviews, which revealed R1’s injuries were consistent with a person who had fallen onto an asphalt or concrete surface and laid there for hours. Therefore, this allegation is substantiated for neglect resulting in R1’s death. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49. An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Staff, Melissa Bridges.