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Operation Guardians Reports

Desert Knolls Convalescent Hospital – Victorville


Patient items soaked in urine were disposed of in a restroom garbage can, rendering the restroom unusable due to the odor. The call lights in patient rooms are often not within patient reach. Two residents reported that the afternoon shift routinely takes a “long time” to answer the call lights.

Restraints were applied to one residents without first obtaining the requisite informed consent. One patient was ordered to be on fluid restriction, but the chart lacked any diagnosis to justify the imposition of the restriction. When the director of nursing was asked why the patient was on fluid restriction, she replied, “the resident has CHF and her son did not want (the resident) to know.” Nothing in the resident’s chart reflects that she has ever had CHF.

One resident’s chart reflected that the resident had an excoriation (similar to an abrasion) on her buttocks. In actuality, the “excoriation” appeared to be a stage three pressure sore, which is much more severe. The wound had been infrequently dressed, and wound care sparsely documented.