Complaint Investigation Report

Allegation: Resident sustained an unexplained fracture while in care.

On July 20,2023, the Department obtained and reviewed C1’s medical records which indicated that C1 was admitted to Sutter Delta Medical Center Surgical Care Unit for pain in his left foot on April 14, 2023, and was discharged the same day. C1 was diagnosed with a displaced fracture in his foot. On April 26, 2023, C1 returned to Sutter Delta Medical Center and was diagnosed with a right-hand scaphoid fracture. Interviews with staff revealed consistent statements of being unable to communicate with C1 regarding pain or hurt, due to C1 being non-verbal. Interviews also indicated staff did not know how C1 sustained fractures, but assumed it was from C1 falling even though the staff did not witness any falls.

Allegation: Resident developed stage 3 pressure injury while in care due to staff neglect.

On April 26, 2023, C1 was admitted to Sutter Delta Medical Center and seen by a wound care registered nurse due to his blisters. C1 had a right forearm blister, a right thigh blister, and a coccyx stage three pressure wound. C1 was diagnosed with systemic inflammatory response syndrome and discharged to a skilled nursing facility on May 5, 2023. Interviews with staff indicated that S2 gave C1 daily showers. S2 admitted during an interview to seeing something on C1’s coccyx that appeared to be like a scar red colored but was not open. S2 also stated that he reported the coccyx blister and documented it on paper but was not certain who he told. S3 stated during an interview that she conducts daily body checks underneath the clients clothing but failed to notice C1 had a stage 3 pressure injury. S1 stated staff did not report any wounds until C1 was found to have blisters on his arm and thigh.