Inspector’s narrative
What the inspector wrote
During the initial visit, LPA Lopez met with Administrator Jill Ford and explained the reason for the inspection. Beginning at 10:40 a.m., the LPA conducted an interview with the Administrator, reviewed facility records, and obtained copies of pertinent records. The LPA also observed the dining room area at 1:50 p.m. and conducted additional interviews with the Administrator at 2:45 p.m.
On 02/21/2023, at approximately 9:30 a.m., Investigator Miles conducted interviews with R1’s resident representatives; on 03/09/2023, from approximately 10:36 a.m. to 1:02 p.m., with residents, Executive Director/Administrator, Director of Health and Wellness/LVN, and staff; on 03/17/2023, at approximately 4:18 p.m., with a Nursing Education Consultant from the California Board of Vocational Nursing and Psychiatric Technicians; and on 03/22/2023, at approximately 12:45 p.m., with staff. Additionally, Investigator Miles reviewed facility file documents related to R1 including incident and death reports, Ventura County (VC) Sheriff’s Office Report #23-10188, Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876, and Ventura County Medical Examiner’s Office Report #150-23.
Information gathered during the course of the investigation reflected that R1 required assistance with all Activities of Daily Living (ADLs) but was able to independently feed self during meals. R1 was not on a special diet but requested that all proteins ordered for dinner were always cut up. On 01/24/2023, during dinnertime, R1 began to choke in the facility dinning room. Resident #2 (R2) and Resident #3 (R3) were seated at the same table and witnessed R1’s head slouch downward, and it appeared R1s mouth was slightly moving but no words were verbalized. Per interviews, no staff were present in the dining area at the time. R2 and R3 then started yelling for assistance and were able to get the attention of Dining Server, Staff #1 (S1). S1 witnessed R1 “grasping” their throat and S1 immediately ran out of the dining room for help. The front desk concierge radioed the facility medical staff. Staff # 2 (S2), Director of Health and Wellness/LVN, responded to R1 and observed R1 on a wheelchair slumped over, motionless and R1’s lips appeared to be blue. Per S2, R1 was checked for level of consciousness but R1 was unresponsive and S2 was unable to find a pulse; therefore, S2 requested staff to call 911. Moreover, S2 claimed they provided two Heimlich thrusts and wheeled R1 out of the dinning room.
Report will continue on LIC9099-C (3rd page).
Interviews with witnesses reflected that it took approximately seven (7) to eight (8) minutes for
S2 to respond. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room. S2 later admitted they did not provide any type of medical or life-saving intervention(s) as they assumed R1’s Do Not Resuscitate (DNR) order applied to them.
Ventura County Emergency Medical Services (EMS) and Fire Records reviewed reflected that, upon arrival of emergency personnel, R1 was “found sitting in a wheelchair with nurse…behind not performing any life-saving procedures.” Paramedics suctioned airway and performed CPR until directed by the paramedic to cease. S2 provided a copy of R1’s DNR order to the VC Sheriff on scene and informed fire personnel, as well. They confirmed the DNR and discontinued life-saving efforts shortly thereafter. At approximately 5:28 p.m., R1 was pronounced deceased by the paramedic. Per the Ventura County Medical Examiner, the official cause of death on the death certificate is listed as asphyxia due to choking with other significant conditions as acute subdural hematoma and Parkinson’s disease.
Based on the interviews conducted and supporting documentation gathered during the course of the investigation, the Department determined that there is sufficient evidence to support the allegation of “Neglect/Lack of Care and Supervision - Resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility”. Therefore, the allegation is deemed Substantiated at this time.
A $500 immediate civil penalty is assessed today. The Nursing Director Betsy Mccoy was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).
Exit interview conducted, civil penalties issued, appeal rights discussed, and a copy of this report issued.
During the investigation, Community Care Licensing Investigations Branch Investigator Phillippe Ryan Miles investigated the allegation of “Resident #1 (R1) choked to death without any medical intervention while under the care and supervision of the facility’, on 02/21/2023, at approximately 9:30 a.m., Investigator Miles conducted interviews with R1’s resident representatives; on 03/09/2023, from approximately 10:36 a.m. to 1:02 p.m., with residents, Executive Director/Administrator, Director of Health and Wellness/LVN, and staff; on 03/17/2023, at approximately 4:18 p.m., with a Nursing Education Consultant from the California Board of Vocational Nursing and Psychiatric Technicians; and on 03/22/2023, at approximately 12:45 p.m., with staff. Additionally, Investigator Miles reviewed facility file documents related to R1 including incident and death reports, Ventura County (VC) Sheriff’s Office Report #23-10188, Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876, and Ventura County Medical Examiner’s Office Report #150-23.
Interviews revealed dinner begins at 4:30 p.m. and the residents arrived at approximately 4:45 p.m. for dinner. Interviews revealed while at dinner, Resident #2 (R2) and Resident #3 (R3) were seated with R1 when R1 began to choke on their meal. R2 and R3 then started yelling for assistance and were able to get the attention of Dining Server, Staff #1 (S1). Per interviews, no staff were present in the dining area at the time. Interviews also revealed the residents could not recall if R1’s pendent was pushed for assistance but stated it was better to yell to get staffs attention versus using the pendent as response times varies. When S1 arrived, S1 witnessed R1 “grasping” their throat and S1 immediately ran out of the dining room for help. S1 ran to the front desk but no one was there. S1 ran to another area where the med-techs are located dispensing medications and the breakroom, and no one was there as well. When S1 returned to the front desk they observed another server alerting concierge of the choking of which concierge used their walkie-talkie to alert the facility medical staff. S1 utilized the stairs when trying to locate staff with the knowledge that the elevators can take five minutes or more to arrive at the lobby floor. Interviews revealed servers do not have walkie-talkies to communicate and only care staff, concierge, med-techs, and house keeping have walkie-talkies.
Report will continue on LIC9099-C (3rd page).
Interviews with Staff #2 (S2) revealed while they were on the third floor of the facility at approximately 5:15 p.m., they received call on the walkie talkie requesting the need for a med-tech or nurse to the dining room stat and they used the elevator to the first floor versus using the stairs. When asked why they did not use the stairs, S2 stated they usually take the stairs, but the elevator was already on the third floor. S2 stated when they arrived, they requested staff to call 911.
Interviews with witnesses reflected that it took approximately seven (7) to eight (8) minutes for the S2 to respond to the stat request for assistance. Interviews conducted with witnesses also reflected that S2 did not perform the Heimlich maneuver or provide any type of life-saving procedures/medical interventions on R1 in the dining room.
Record review of the pendent call records for R1 revealed R1’s last pendent call for service on 01/24/2023 was at 4:39 p.m. and staff responded within a minute. Pendent call records for R2 and R3 reviewed no calls for service on 01/24/2023.
The Ventura County Emergency Medical Services (EMS) and Fire Report #23-0007876 revealed at approximately 5:16 p.m. a 911 call was received regarding a person who was choking and not breathing.
Based on interviews conducted and supporting documentation obtained during the course of the investigation, there is insufficient evidence to support that staff did not respond to a pendent call for assistance timely. Although, there is sufficient evidence to support staff did not respond timely to an emergent situation. Therefore, a citation will be issued for this deficiency under separate cover.
During the investigation it was also revealed that S2 did not have a valid first aid certificate. Record review revealed S2’s first aid certificate expired in February 2022. A deficiency related to this will also be addressed under separate cover.
Exit interview conducted, and a copy of this report issued.
