Complaint Investigation Report

Interviews with facility Licensee and caregiver staff (S1 & S2) state that these individuals did not observe or were aware of any bruises, sores or injuries on R1's body. Although R1 does not require bed reposition based on R1's physician's report, staff were aware of R1's behavior of sitting on their hands and R1's right had appeared red on 3/9/2023. This resulted in severe ischemia potentially due to R1 not being monitored and R1's hands not moved or off-loaded until the following morning on 3/10/2023. Staff did not provide proper assessments and supervision regarding R1's multiple pressure wounds that were observed by emergency ambulance staff and medical center staff upon R1's admission to Sutter Solano Medical Center.

Interviews with Sutter Solano Medical physician and registered nurse staff (I1 & I2) indicated that R1's wounds to the right hip and wrist/hand was potentially caused from cut blood flow circulation for a "prolonged time" and "at least several hours" without staff providing proper supervision, assessments and observation of R1's wounds and overall health condition while in the facility.

Today, 7/28/2023 the Department An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care.

The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).