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Proper Staff Supervision an Issue at Sunrise Convalescent Hospital in Pasadena, Report Finds

The staff members at a nursing facility should not become the decision makers with regard to serious medical decisions. Potentially fatal health issues should not go undiagnosed or without treatment. Patients should not go without their prescribed medications. Residents who cannot protect themselves or care for themselves should not be able to leave a facility without proper supervision. Unfortunately, these types of incidents occurred at the Sunrise Convalescent Hospital in Pasadena. On December 14, 2011, members of a multi-agency task force called Operation Guardians conducted a surprise inspection of the Sunrise Convalescent Hospital. Months later, they released reports covering many of their findings. Sadly, many of their observations were troubling.

Residents Left the Building Without Supervision

According to the report, the majority of the residents in this Pasadena nursing home are incapable of caring for themselves or even making decisions for themselves. Therefore, it is in their best interest to be carefully supervised when exiting the building. Unfortunately, the design and layout of the facility allows residents to leave from a number of exits. The facility has not attempted to install a security system in order to prevent residents from leaving the nursing home unsupervised.

Lack of Informed Consent

Inspectors found that many residents were allowed to sign their own advance directive forms. In other words, residents who were not of sound mind were allowed to approve their own forms of treatment relating to their end-of-life care. For example, one patient had a daughter who was legally responsible for making her medical decisions. The facility chose to allow the patient to sign her own consent forms instead of consulting with the daughter. Additionally, there were cases in which the nursing staff did not even follow the advance directives.

Failure to Supervise the Nursing Staff

The report specifically points out that many of the new nurses were performing adequate patient reviews and skin breakdown evaluations. Unfortunately, there were failures to:

  • Consult consent forms before providing care
  • Follow through on changes of conditions
  • Inform physicians and family members about the changing conditions
  • Provide timely nursing assessments
  • Accurately update fall risk assessments
  • Perform nursing assessments of meal intakes

These failures can reflect both insufficient supervision as well as insufficient staffing.

Other Troubling Findings

The following observations were made at the Sunrise Convalescent Hospital on December 14, 2011:

  • A patient was receiving gastrostomy tube feedings with his head elevated at only 15 degrees. Patients receiving gastrostomy feedings with their head below 35 degrees run the risk of aspirating.
  • Another patient was in danger of suffering from aspiration as well. She also had a soiled gown with yellow/green drainage. Further investigation found that the patient and her family did not want the GT replaced and yet the facility sent her to Silver Lake Hospital for treatment against their wishes.
  • Inspectors described the facility as "extremely dirty" and "heavily soiled."
  • The building was in disrepair and many of the items were damaged.
  • There were numerous maintenance issues that put residents at risk. These types of issues can pose both safety risks and infection risks.
  • Many residents were in danger of suffering from neglect because their call lights were out of reach.
  • Several residents had to suffer the indignity of being exposed while being transferred by chairs to the shower rooms.
  • A number of doors did not have the names of the residents posted, which poses a safety issue.

Protecting Victims' Rights

Anyone who worries that their loved one has been mistreated or neglected at a nursing home would be well advised to report the incidents to authorities. The experienced Pasadena nursing home abuse lawyers at our law firm can help injured victims and their families get justice and fair compensation for their losses. We have a long and successful track record of helping victims of nursing home neglect. Please contact us for a free, comprehensive and confidential consultation.


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