Staff and an outside party involved with R1's care left messages for R1's doctor, and the outside party requested to wait for R1's doctor to respond before sending R1 out. R1's doctor subsequently returned the call later in the day and instructed to send R1 to the hospital, which was completed.

An interview was conducted with an outside source (OS1) familiar with R1's care and the incident in question. OS1 corroborated that R1 experienced a change in condition the day in question. OS1 informed that they observed R1 to be in severe pain at the facility and R1's physician instructed for R1 to be sent to the hospital. The facility initiated non-emergency transport, which was upgraded to emergency transport due to R1's condition becoming critical. R1 was diagnosed with a systemic infection and an acute kidney issue during the hospital admission.

Facility and outside source records relevant to the investigation were reviewed. R1's Physician's Report, dated 05/20/2025, revealed that R1 had diagnoses of cognitive impairment, a kidney condition, as well as multiple disorders of the digestive system. The facility submitted an Unusual Incident/Injury Report regarding the incident in question. The report stated that R1 complained of stomach discomfort, staff conducted an assessment, and elevated the situation to management, who conducted an additional assessment and found R1 to have abdominal pain. R1 was given an ice pack for comfort and was provided pain medication. R1's vital signs were checked and two conversations were had between staff and R1's decision maker regarding R1 being taken to the ER or urgent care; the decision maker requested to wait to hear back from R1's doctor. Upon return call, R1's doctor advised for R1 be sent to the emergency room. Medication Administration History for R1 showed that R1 received pain medication the day of incident, corroborating staff statements. The document noted that the pain medication provided was effective.

Facility nursing notes documented that R1's vital signs were checked due to R1 experiencing fatigue with stomach pain; R1 received pain medication per request. The facility advised R1's decision maker that R1's primary care physician would be contacted, and an inquiry was made by the facility whether R1 should be taken to urgent care due to R1's vital signs being out of baseline with low food intake. Facility management advised that R1 should be taken for evaluation. Facility staff left a message for R1's doctor at approximately 1600 hours. R1's decision maker requested to wait for R1's doctor to return the call. The phone call was had with R1's doctor at approximately 1820 hours and it was advised for R1 to be sent to the hospital for evaluation. (Continued on LIC9099 p.3)

A discussion was held between staff and R1's decision maker regarding emergency versus non-emergency transport. EMT transportation arrived at 1930 hours and determined that R1 could not be transported due to their vital signs being out of baseline; R1 was then sent to the hospital by paramedics via 911 at 1945 hours.

EMS documentation stated that R1's condition had progressively declined throughout the day, and their vitals had become too unstable for safe transport via Basic Life Support (BLS) upon arrival. The call was upgraded to Advanced Life Support (ALS) and R1 was transported via ambulance to the hospital. Hospital records on 06/29/2025 showed that R1 suffered from multiple gastrointestinal comorbidities and was admitted due to an acute kidney condition, low blood pressure, and possible infection. R1 was placed on hospice during this hospital admission and given comfort care measures.

An interview was conducted with a medical provider (OS2) familiar with R1's care and the incident in question. OS2 informed that R1's kidney failure had clinically begun a minimum of two to three days prior to presenting at the hospital. The condition resulted in a full-body organ shut down. OS2 informed that R1's passing was not caused by the hours spent waiting to bring R1 to the hospital, and that a change in condition of this type would not be noticeable until the person significantly dropped below baseline. OS2 further informed that patients did not always present immediate signals of infection; that it can sometimes gradually build up before entering the bloodstream.

Involved parties and witnesses to the incident provided conflicting statements regarding how/when the decision was made for R1's transportation to the hospital. Interviews showed that R1 received pain medication and an ice pack at the facility for comfort and pain management. No evidence was found to corroborate the claim that staff were explicitly told to have R1 transported to the hospital via emergency transport only, and defied the order. The evidence showed that ultimately, R1's fatal medical chain reaction was set in motion days in advance, and was not due to a delay in medical care. A preponderance of evidence was not found to prove that a delay in care caused R1's passing. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Assistant Supervisor Alma Sanchez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Facility and outside records showed that R1 was transported to the hospital via emergency transport on 06/29/2025 at approximately 7:45pm on the day in question. The medication administration record showed that R1 received bedtime medications this same day, which would not have been possible due to R1 not being present at the facility.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Assistant Supervisor Alma Sanchez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.