Complaint Investigation Report

Hospital records indicate that C1 was admitted on 12/26/21 for difficulty swallowing and not following commands; however, medical staff observed upon presentation that C1 had developing deep tissue injuries at the sacral and right ischial areas, with 90% chance of evolving into Stage 3-4 pressure injuries.

The Department has investigated this allegation, and per records review and interviews has found that the preponderance of evidence standard has been met, therefore, the allegation is Substantiated. Deficiency cited on the 809D form, per California Code of Regulations, Title 22, Division 6, Chapter 8.

A $500.00 immediate civil penalty is assessed due to the wound injuries.

Failure to correct the deficiency by the POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report and the Appeal Rights was provided.