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Operation Guardians Reports

Golden Cross Health Care – Pasadena


“Failures of nursing care were seen in almost every case. In particular, there was inadequate wound prevention and treatment, dehydration, inadequate psychotropic medication practices, and poor end-of-life care identified.” One resident developed maggots in an open wound in his rectum likely due to the staff’s failure to keep the wound clean. In another instance, records showed that a resident’s pressure sore had resolved. Upon inspection, it was a “full-thickness left heel ulcer.” On another occasion, the physician assistant and a staff nurse had documented treating the same pressure sore at the same time on the same day, each one treating the wound differently. The conflicting notes indicate potential record falsification.

The facility did not note dehydration as a diagnosis for multiple residents despite “clear documentation of dehydration” in the residents’ records. The facility also improperly medicates its residents with antipsychotic drugs. “Deficiencies in this area include: inadequate verification of informed consent; inappropriate monitoring and lack of monitoring; and lack of monitoring for adverse drug effects.” Patients are even treated with antipsychotic drugs that have reactions to medications they are already taking. “[One resident] was given Lorazepam for ‘paranoia’, whereas Lorazepam is an antianxiety drug, not indicated for treatment of this disorder” The medical record reflected that the drug was only being administered when the patient was “verbally aggressive,” thus being used as a chemical restraint. Lorazepam can make problems like “verbal aggression and resisting care worse instead of better.”