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Operation Guardians Reports

Braswell’s Hampton Manor – Yucaipa


“There were deficient facility practices in the areas of infection control, end of life care, nutrition and hydration care, and nursing services…Residents at this nursing facility are being avoidably harmed due to these deficient practices.” A nurse ordered a urinary culture on a resident. The results of the culture reflected that the resident had a urinary tract infection. Nine days later the infection had yet to be treated. That day, the resident was observed to be “extremely agitated.” She was given a tranquilizer injection and put back in her hospital bed. Two days later, the same resident had fallen again, this time breaking her hip and wrist. She died at the facility ten days later. Her medical record did not contain the results of her initial urinalysis, the inspectors had to obtain the results from the testing laboratory.

A similar incident occurred with another resident who had exhibited a pale-white appearance and had refused to consume her food or medication four days after she suffered a fall. No investigation had been conducted into the reason for the fall. The fourth day after the fall, a urinalysis was ordered, but not conducted for another two days. The day after the urinalysis, she was admitted to the hospital for severe dehydration and UTI. She died five days later. This facility also has a large number of residents with c-diff infections. The medical director admitted that c.diff infections are “rampant in this community.” These infections can be easily prevented with hygienic measures and adequate infection control precautions. One resident stricken with a bout of diarrhea, who the staff identified as having been potentially infected with c-diff, was observed in an Occupational Therapy session with other residents, placing other residents in danger of exposure to c-diff.

Finally, one resident whose medical progress had not been updated for over a week at the time of inspection, died the day following a chart notation reflecting that the resident had a “wet cough” and was vomiting “yellow thick sputum.” These symptoms indicated the patient had aspiration pneumonia, and was likely exhibiting symptoms over a period of time. Staff likely ignored the symptoms until it was too late.