Complaint Investigation Report

On 06/30/24 the resident was transported to the hospital. It was reported that R1 was diagnosed with 3 rd degree burns on the posterior left leg and posterior right leg, hypotensive dehydrated, hypothermic, and heat stroke/heat exhaustion. It was reported that the resident needed a higher level of care and was sent to a Skilled Nursing Facility (SNF). While at the SNF, it was determined that the resident needed a higher level of care and was sent to a medical center for observation and treatment.

On 07/13/24 the resident was transported to the medical center. There is where it was reported that the resident was suffering from burns to her posterior buttocks, thighs, and legs. UC Davis documents state that the resident had approximately 9% Total Body Surface Area (TBSA) to the left posterior leg and right lower posterior leg due to a scald burn of the resident laying on the concrete.

On 09/19/24 the R1 was seen by the physician who reported that R1 was being seen for burns to the right leg and a burn to the left leg. In addition, the physician’s notes state that the resident has a “Necrotic tendon/tissue with necrotic tendon unattached distally…” The resident suffered from dead tissue/tendon that couldn’t be saved due to a lack of blood flow, or devascularization . A video was reviewed by LPA Gurriere of the dead tendon.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

At the time of the complaint visit, an immediate civil penalty of $1000 shall be assessed for a violation of California Code of Regulations Personnel Requirements - 87411(a) cited on 07/10/24 and 10/29/24. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49.