Complaint Investigation Report

Based on the review of medical records from Santa Clara Valley Medical Center, R1 was evaluated by the burn team, who did not feel the skin lesions R1 had were consistent with typical burns.

Dermatology was consulted and they believed that the skin lesions R1 had were likely related to an underlying bacterial infection and intertrigo. Blood tests confirmed the presence of bacterial skin infections, including Group A Streptococcus (GAS) and Pseudomonas.

Infectious Disease was also consulted, and they noted the possibility that R1 presented with GAS-mediated toxic shock syndrome, which can cause widespread erythema and desquamation, potentially explaining the ulceration on R1’s right leg. Staph toxic shock syndrome was considered less likely, as blood cultures grew GAS. The source of the GAS infection remained unclear but may have originated from cellulitis or a leg wound. No retained foreign body was identified. A superficial swab of the leg grew Pseudomonas. Infectious Disease indicated that the GAS infection could have originated from R1’s burns, but it was unlikely to be caused by hot water, as the timing did not align with how such infections typically develop because R1 had sought treatment the same day they allegedly sustained the burn.

Based on the review of R1’s Physician's Report, dated 04/25/2024, R1 was able to care for all personal needs, including bathing and dressing.

Based on the review of R1’s Functional Capability Assessment, dated 04/25/2024, R1 was able to bathe or shower without help, dress independently, and manage their own personal hygiene.

Based on the interview with R1, R1 stated they took a shower by turning on the bathroom faucet and using a bowl to wash themselves for about 20 minutes. R1 said, “I guess the water was hot and I didn’t feel it.” R1 explained there was no one else in the bathroom and that no one assisted them in bathing. On the same day, R1 informed staff that their leg hurt and that they had fallen. The staff then called 911. When asked whether the staff delayed in calling paramedics, R1 responded “No.” R1 did not make any complaints or claims prior to their hospitalization.

Based on an interview with R1’s roommate (RM), RM did not observe any burns, redness, blisters, or skin conditions on R1. RM did not recall hearing R1 complain of pain, did not witness R1 fall, and stated that they did not pay much attention to R1.