complaint·August 15, 2023

(continued from page 1; 9099) On 05/01/2023, from 2:47pm to 4:30pm, Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced initial 10-day complaint visit to the facility. During the visit, LPA Ascencio conducted a physical plant tour at 2:55pm, and obtained pertinent documents. The LPA met with Administrator Victor Hernandez at 3:00pm. The LPA determined further investigation was needed and informed the Administrator the complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Sonia Sandoval. On 05/09/2023, at approximately 11:34am, Investigator Sandoval conducted an interview with R1’s resident representative; on 05/18/2023, from approximately 10:10am to 12:20pm, with Los Robles Healthcare hospice nurse, R1, facility residents, Administrator, and staff; on 05/31/2023, from approximately 11:55am to 12:35pm, with Staff #1 (S1) and Staff #2 (S2). In addition, Investigator Sandoval reviewed Los Robles Healthcare medical records, text messages from R1’s resident representative pertaining to the incident, photos of R1’s injuries, facility file documents related to R1, and personnel records for S1 and S2. A review of R1’s Physician Report, dated 04/19/2023, indicated R1 was bedridden with a primary diagnosis of Type II Diabetes Mellitus (DM) with diabetic peripheral angiopathy with gangrene. R1 was unable to manage their own treatment/medication/equipment. R1’s conditions included bowel and bladder impairment, motor impairment/paralysis, had a history of skin condition or breakdown, and required continuous bed care. R1’s mental conditions included confused/disoriented. However, R1 was able to follow instructions and communicate needs. R1 was unable to bathe, dress/groom, feed self or administer their own prescription medications. R1 was receiving hospice care at the time of admission to the facility on 04/20/2023. (continued on page 3; 9099-C) (continued from page 2; 9099-C) The investigation revealed that Los Robles Healthcare hospice treated R1 three times per week on Mondays, Wednesdays, and Fridays, typically in the afternoon. The hospice nurse provided wound care to R1 for the amputated toes on the right foot. On 04/26/2023, between 12:30pm and 2:00pm, the hospice nurse provided wound care and did not observe anything on R1’s arm or torso. The next time the hospice nurse saw R1 was on the next scheduled visit on Friday 04/28/2023, at 10:30am. The hospice nurse began the wound care and skin assessment and immediately noticed the burn on R1’s left forearm. The nurse asked R1 what happened and R1 said R1 burned themself with coffee. The nurse then saw the additional burn on the left side of R1’s torso. The nurse contacted R1’s resident representative to inform of the burns and ask if the facility had notified them of the incident. R1’s resident representative stated the facility did not notify them of the incident. The nurse took pictures of the burns and sent to the hospice supervisor and to R1’s resident representative. The hospice nurse indicated the burn on R1’s forearm was assessed to be a second-degree burn based on the appearance of blistering and the skin was peeling away. The pictures were sent to the hospice Dr. Sherman who confirmed the stage of the burn. The hospice nurse was then ordered to treat the burn in addition to the wound care provided on the subsequent visits. Hospice notes indicate the burn wound on the left torso/rib cage was assessed as closed with a pink wound bed and attached wound edges, no treatment needed. Information obtained from the staff member statements confirmed that R1 required supervision and assistance while eating. Former staff S1 confirmed on the day of the incident during breakfast, R1 was left unsupervised by S1 while S1 assisted another resident. During that time, R1 spilled coffee on themself and burned their left forearm and torso area with the hot liquid. The Administrator confirmed when they became aware of the incident, they did not seek medical attention for R1 or report the incident to the hospice agency or to R1’s resident representative. (continued on page 4; 9099-C) (continued from page 3; 9099-C) The information obtained during the Department’s investigation found that R1 sustained an injury (second-degree burn) when the facility neglected to provide supervision while R1 ate; failed to seek medical attention in a timely manner; and did not report the serious injury to R1’s resident representative or hospice agency. Therefore the allegations “Neglect/Lack of Care and Supervision – Facility failed to seek medical attention in a timely manner when facility resident sustained an injury (second degree burn) while in care at the facility”; “Neglect/Lack of Care and Supervision – Facility failed to provided supervision when facility resident sustained an injury (second degree burn) while at the facility”; and “Facility staff did not report serious injury to resident’s responsible party” are deemed Substantiated at this time. Regarding the allegation "Facility staff failed to treat resident with dignity by scolding and yelling at resident", based on interviews with witnesses, S1 was observed scolding R1, shaking their finger at R1 and raising their voice at R1. Based on interviews, this allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.