Medical records document that R1 had been previously diagnosed with AFIB (Atrial Fibrillation), Congestive Heart Failure and COPD (Chronic Obstructive Pulmonary Disease) and was in poor health with a very high Body Mass Index prior to contracting COVID-19.

Medical records and physician statements also provided, on 05/06/2021, R1 was “critically sick” when admitted to the hospital. Emergency Room physicians contacted R1’s wife and recommended a transfer to a higher level of care, as Fairchild Medical Center did not have “critical care nor pulmonary here.” R1’s wife, “adamantly stated she wanted him to stay at Fairchild.” Medical records further noted that the physician, “wanted pt (patient/R1) transferred to higher level of care but wife refused so I am forced to admit him here and do what I can to reverse his condition.”

In the discharge summary, it is noted that R1, “remained steadily declining throughout his stay until family came to visit.” Medical records state, after discussion, “his prognosis

very poor likelihood of significant or meaningful improvement,” R1’s family requested to withdraw support and institute comfort measures. On 05/08/2021, at 1805 hours, R1 passed away at FMC.

R1 Primary Care Physician and two attending hospital Physicians were interviewed. All three stated that they could not say that earlier medical treatment would have altered the outcome for R1.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred

An exit interview was conducted and a copy of this report, dated 12/08/2021 was emailed to Annette Hart, Interim Executive Director (IED).

The Department interviewed facility staff, residents, and reviewed records. During the investigation, it was determined that there was sufficient evidence to substantiate; Failure to seek timely medical attention for resident. Resident one (1) (R1) tested positive for COVID-19 on 04/28/2021. It was initially reported that R1 was showing symptoms of respiratory distress and asking to go to the hospital days before being sent to the hospital on the morning of 05/06/2021. R1 died on 05/08/2021. The death certificate was obtained and listed the cause of death for R1 as Cardiopulmonary Arrest, Pneumonia and COVID-19.

Medical records were obtained and documented that R1 had a history of AFIB (Atrial Fibrillation), Congestive Heart Failure and COPD (Chronic Obstructive Pulmonary Disease). On 03/30/2021, following a five-day admission to the hospital for difficulty breathing, R1 was prescribed a PRN inhaler and nebulizer.

Fifteen (15) staff were interviewed. Eight (8) 8/15 staff stated they heard or observed R1 showing symptoms of respiratory distress as early as 05/02/2021. Six (6) 6/15 staff stated they either heard or were aware that R1 had asked to be sent to the hospital and was denied. Multiple staff corroborated that R1’s symptoms were discussed amongst management days prior to R1 being sent to the hospital. Multiple staff corroborated that they heard Executive Director (ED) state, “You should have seen him (R1) last night,” when concerns were brought to her attention regarding R1 condition. One staff reported that she overheard a conversation between ED and Resident Care Director (RCD), after R1 was sent to the hospital, where RCD expressed concern that she had not sent R1 out to the hospital sooner.

RCD was interviewed and denied any knowledge of R1 showing signs of respiratory distress or asking to go to the hospital, prior to being sent on 05/06/2021. RCD stated she did not remember seeing R1 at any time between 05/03/2021 and 05/05/2021 and did not remember hearing anyone talk about concerns with R1’s health.

Three different physicians were interviewed who had treated R1 on different occasions, including the admitting physician in the Emergency Department on 05/06/2021. All three physicians stated that, although it may not have changed the outcome of his condition, if R1 had asked to be sent to the hospital, it is the patients right to be sent.

ED was interviewed and denied any knowledge of R1 showing signs of respiratory distress or asking to go to the hospital. ED stated that she personally checked on R1 on the evening of either 04/04/2021 or 04/05/2021 and R1 “seemed fine.”

All care staff interviewed stated that care staff had the understanding that they were to contact RD or RCD to authorize a resident being sent out to the hospital. When interviewed ED admitted that unless a resident’s condition was “super obvious” in needing to be sent to the hospital, staff were instructed to call herself or RCD to assess the resident before sending the resident to the hospital.

Based on the findings of this investigation LPA finds allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 rules and regulations, Health and Safety Codes, and Welfare and Institutions Code as well as a 500.00 civil penalty.

An exit interview was conducted and a copy of this report, dated 12/08/2021 was emailed to IED. The following allegations have already been cited and Plans of Corrections (POC) have been turned in.

-Facility failed to implement Covid-19 mitigation measures for resident safety- Substantiated cited 05/17/2021 POC received 06/04/2021.

-Administrator is interfering with the department’s efforts of corrective actions for a Covid 19 outbreak- Substantiated cited 06/15/2021 POC received 06/16/2021

-Administrator retaliation toward staff for reporting a complaint- Substantiated cited 06/15/2021 POC received 06/16/2021.