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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1330753

Case Details

VAERS ID: 1330753 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Confusional state, Hypoxia
SMQs:, Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown, but per facility nurse, pt is NOT on blood thinners.
Current Illness:
Preexisting Conditions:
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: J&J vaccine was administered to patient. Consent form states that patient will be receiving J&J vaccine today. Pt is confused per medical baseline. Notified facility nurse, RN that I will be given J&J to patient and was okay with giving. After vaccine was given a second facility nurse, RN confirmed that pt was supposed to received second dose of Pfizer vaccine today. Pt was closely monitored in area for 30 minutes, facility Dr was notified. No acute distress noted, vital sign stable, no reactions noted, no active bleeding noted during 30 minutes of observation. Pt was taken back to her room and 15 minutes after observation at around 09:35AM, facility staff notified pt was desatting, was placed on oxygen and ambulance was called and taken to emergency room.

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