Complaint Investigation Report, 05/10/2024 — Savant of Burbank East, Burbank CA

Allegation #1: Staff did not order resident’s oxygen tank.

The details of the complaint alleged that resident #1 (R1) was without an oxygen tank for several days. The complainant reported that an oxygen tank was required when (R1) was transferred from a skilled nursing facility (SNF) on 08/16/23. (R1) was sent without oxygen by the (SNF) and informed that Burbank Senior Villa East would be providing the equipment. The complainant added that (R1) again did not have an oxygen tank on 09/18/23 and that (R1’s) level was down 70%.

According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 08/17/23) and Admissions Agreement (dated: 08/17/23), (R1) was admitted at Burbank Senior Villa East on 08/17/23. A voluntary terminated of residency on 10/31/23 by (R1) due to needing a higher level of care.

On 09/22/23, between 09:00 am – 03:00 pm, Licensing Program Analyst (LPA) Antonia Alvizar interviewed resident #1 (R1) using Language Link Translator Operator #16459. (R1) stated that staff did order an oxygen tank and no further information was provided.

On 05/08/24, between 10:30 am – 11:45 am, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (8) out of (9) residents #2 - #9 (R2-R9) claimed to have no issues with oxygen tank as it is not a prescribed equipment authorized by their medical physician. (R7) a former oxygen tank user reported never having issues obtaining an equipment through home health or primary physician.

On 05/08/24, between 12:20 pm – 01:17 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed (4) out (4) staff #1-#4 (S1-S4) who denied knowing (R1) not having an oxygen tank on 08/17/23 and 09/18/23. (S1-S4) acknowledged that (R1) required the equipment and that home health with (R1’s) primary physician is responsible for ordering the equipment. (S1-S4) stated (R1) was never without access to an oxygen tank. (S1-S4) stated if (R1’s) physician's order did not arrive timely, (R1) would be provided with a substitute supplied by the facility.