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Understaffing May Be a Source of Problems at Pasadena Nursing Home

There are many nursing homes in Los Angeles County that put their residents in harm's way. To help raise awareness about the health concerns at nursing homes in California, the Office of the Attorney General sent out a multi-agency task force called Operation Guardians to inspect several nursing facilities that care for the elderly in California. On December 13, 2011, investigators with the Operation Guardians team conducted a surprise inspection of Golden Cross Health Care in Pasadena. Unfortunately, there were many issues that were discovered during the one-day inspection. It is important to remember that it is the legal responsibility of all care providers to provide a reasonably clean and safe environment along with adequate medical attention. This nursing care facility was apparently one of many in the state that failed to live up to those standards in many different ways.

Findings at the Golden Cross Health Care facility

There are many ways in which a nursing facility may put elderly patients in risk of suffering a fatal injury or illness. A few examples of observations made at this Pasadena nursing home on December 13, 2011 include:

  • Staffing levels for the facility were below the legally required 3.2 hours per resident day on two of the six days randomly reviewed by the inspectors. The average hours per resident day was 3.12 hours.
  • There were also health and safety issues as well as possible infection control issues. For example, one bedside stand had soiled gloves sitting on it. One bedspread had soiled clothing on it. Furniture required deep cleaning. The shower room had feces on the floor. Some certified nursing assistants were not wearing gloves while handling soiled linen.
  • Some patients had call lights that were out of reach. This raises serious questions of neglect. Several residents even told inspectors that when they did use their call lights, they were not answered in a timely manner.
  • Two residents with heel ulcers were suffering from dehydration. The facility did not list dehydration as a diagnosis on either of their records.
  • There was a failure to provide adequate preventive care to residents who had pressure ulcers.
  • In one case, the failure to provide adequate wound care was so "grossly evident" because the victim developed maggots in an open wound in his rectum. The facility did not report this or suspect that neglect was occurring.
  • There were cases of patients being given psychotropic medication without receiving informed consent.
  • One patient was left lying in bed for several hours without proper repositioning to prevent pressure sores. He had a history of skin tears to his buttocks and was suffering from a State II pressure ulcer to the sacral area. The certified nurse said that the patient screamed when he was repositioned but during the investigation, he was cooperative and did not express signs of discomfort.
  • Another patient was unable to communicate and the facility failed to provide any assistance to help him communicate his needs.
  • A patient who was suffering from a State IV pressure ulcer on her right heel had a treatment authorization record containing contradictory orders. Inspectors found the instructions to be confusing and that the physician should be contacted to determine the correct wound care order. Additionally, there were blank days on her records when she should have received treatments.

Protecting Residents' Rights

It is crucial that elderly patients receive adequate care and supervision. Facilities that foster an environment where neglect and abuse occur can be held accountable for the damages they cause. The experienced Pasadena nursing home abuse lawyers at our firm can help review the circumstances of a case to determine when a patient suffered an illness or injury because of negligence or wrongdoing. It is unacceptable for nursing home residents to be provided with substandard care at a time in their lives when they should be treated with dignity and respect. Negligent nursing homes that put profits over the people they are supposed to serve must be held accountable.


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