complaint·February 2, 2024

Admission Agreement (dated 09/18/2022) and Appraisal Needs and Services (dated 05/01/2023). LPA conducted interviews with Administrator, one (1) out of two (2) staff members and two (2) out of four (4) residents. Investigator Douglas conducted interviews with Medical Social Worker (on 07/19/23), R1, Administrator and two (2) staff members (on 07/28/23). Moreover, on 08/23/23 the Investigator visited “West Hills Hospital Burn Center” and conducted an interview with the Chief Medical Officer and obtained Medical Records for R1. Lastly, the Investigator conducted an interview with a witness on 08/28/23. Allegation: Resident sustained a burn in care due to lack of supervision The investigation findings revealed that R1 had been living at this facility since September 18 th , 2023. Although, R1 was able to communicate his/her needs and feed self, due to R1’s physical condition, R1 required assistance with the Activities of Daily Living (ADL). On 05/26/23, R1 was in bed, watching TV and facility staff served very hot soup (requested by R1) for lunch. S2 placed the hot soup on the “over the bed” tray/table (on wheels) next to R1’s bed and left the room. No staff made sure that the table was stable and R1 was in a position in which they were able to prevent the spill. When R1 went to grab the soup from the table it spilled on his/her thigh causing the burn. It was revealed that the tray/table was loose causing it to wobble, which contributed to the soup spilling. When R1 called for help, Staff #1 (S1) and Staff #2 (S2) went to R1’s room, placed R1 on a wheelchair and then cleaned the bed. Immediately, after R1 was changed/treated, the facility staff contacted the Administrator and notified of an incident. Administrator instructed them, via telephone, to put ice and ointment (aloe vera) on the wound. After the Administrator arrived to the facility and observed R1’s burn did not appear to be blistering and R1 did not complain of any pain, Administrator determined to wait for a Home Health agency that was already scheduled to come to the facility in the coming days. However, the Home Health agency did not come on their scheduled treatment date and even then, R1 was not taken to the hospital. Since R1 had also already been scheduled to see his/her primary doctor in the coming 5 days, the Administrator made a decision to wait, although by the 2 nd or 3 rd day, the burn began to blister. On 05/30/23, during the scheduled doctors appointment, the doctor recommended R1 be transferred to the burn center because they did not have a burn unit at that particular Kaiser facility. Once admitted to the hospital (on 05/30/23) R1 was diagnosed with large 2 nd /3 rd degree burn to his/her left thigh. Interview with the Chief Medical Officer revealed that R1 needed to be hospitalized for 16 days as a “skin graft” was needed to repair the damage done to R1’s thigh as a result of the burns. Continue on LIC9099-C Per the medical report, it was noted that on, 06/01/23, a debridement was performed down to the deep dermal tissue and an application of homograft cadaveric skin to the left thigh. Allegation: Facility staff did not seek timely medical attention for resident. On 05/26/23, R1 was in bed, watching TV and the facility staff served very hot soup (requested by R1) for lunch. S2 placed the hot soup on the “over the bed” tray/table (on wheels) next to R1’s bed and left the room. No staff made sure that the table was stable and R1 was in a position in which they were able to prevent the spill. When R1 went to grab the soup from the table it spilled on his/her thigh causing the burn. Immediately, after R1 was changed/treated, the facility staff contacted the Administrator and notified of an incident. Administrator instructed them, via telephone, to put an ice and ointment (aloe vera) on the wound. After the Administrator arrived to the facility and observed R1’s burn did not appear to be blistering and R1 did not complain of any pain, Administrator determined to wait for a Home Health agency that was already scheduled to come to the facility in the coming days. However, the Home Health agency did not come on their scheduled treatment date and even then, R1 was not taken to the hospital. Since R1 had also already been scheduled to see his/her primary doctor in the coming 5 days, the Administrator made a decision to wait, although by the 2 nd or 3 rd day, the burn began to blister . Even then, the Administrator did not call 9-1-1, instead the facility staff simply treated R1’s injury with over-the-counter ointment for 4 or 5 days. When R1 was ultimately taken to the hospital, R1's wound was classified as a 2 nd or 3 rd degree burn to 4% of R1's body. Based on the information gathered, there is sufficient evidence to conclude that the above allegations are Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting R1's serious bodily injury. The Licensee/Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Deficiencies/civil penalty were issued per CA code of Regulations Title 22 on LIC-9099D Exit interview conducted, appeal rights explained and a copy of this report signed and delivered.