F0580

D

Failure to Notify Responsible Party of Resident Burn Injury

Torrance, California Survey Completed on 02-11-2026

Penalty

Fine: $14,015

Summary

The deficiency involves the facility’s failure to notify a resident’s Responsible Party (RP) of a burn injury in accordance with its policy on changes in a resident’s condition or status. The resident, who had Parkinson’s disease and moderately impaired cognition per the MDS dated 1/21/2026, sustained a thermal burn when a cup containing hot liquid was placed on the overbed table and spilled onto the resident’s right lateral leg, causing a second-degree, partial-thickness burn with erythema and superficial skin peeling. The nursing note dated 12/28/2025 documented the injury but incorrectly described the burn as being on the right forearm instead of the right leg.

Following the incident, LVN 1 stated he did not notify the resident’s RP about the burn injury and claimed he had endorsed the resident’s injury status to an unidentified charge nurse on the 3 p.m. to 11 p.m. shift. RN 1 acknowledged that LVN 1 reported the burn injury to her but stated she was unaware that the RP had not been notified and confirmed that she also did not notify the RP. The Administrator later reported that the RP called on 1/5/2026, expressing frustration at not having been informed of the burn injury that occurred on 12/28/2025. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” dated 4/2011 showed that the Nurse Supervisor/Charge Nurse is required to notify the resident’s family or representative when the resident is involved in any accident or incident resulting in injury, including injuries of unknown source, which did not occur in this case.