SONOMA DEVELOPMENTAL CENTER D/P SNF
P.O. BOX 1493, ELDRIDGE, CA 95431
Citation Number: 150003148
Citation Date: 8/13/2007
Violation Date: 10/22/2005
Class: AA
Penalty: $ 90000.00

On 10/22/05, a totally dependent 25 year old resident who was confined to a special wheelchair, had highly impaired vision, limited use of both arms and partial loss of voluntary movement died after swallowing two plastic-handled cotton-tipped swabs. The plastic punctured his internal organs and he bled to death. The swabs were being used for oral hygiene. It was not clear how the resident came to have swallowed the swabs. Comments in the Autopsy findings noted it was very unlikely that he put the swabs in his own mouth due to his limb deformities.