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Operation Guardians Reports

Yuba Skilled Nursing Center – Yuba City


“Systemic problems in the nursing department included the listing of inaccurate diagnoses, poor end-of-life care, avoidable dehydration and inadequate fall prevention.” The facility had a “high” incidence of pressure sores acquired after a resident’s admission to the facility. This may be related to the fact that the nursing staff fails to adequately monitor its patients. One patient’s physician orders advised the nursing staff to perform wound care twice per day, yet in a three week period the wound had only been cared for on 9 out of 21 total days. Nursing neglect is present in other areas, notably the frequency of resident dehydration. One severely dehydrated resident’s chart reflected that 80-100% of the food and water offered to the patient had been consumed. Given that the patient’s blood test reflected particularly high sodium and urea nitrogen levels (clear signs of dehydration), the charted information was likely false.

Another patient’s medical chart reflected that the patient suffered from hypokalemia (low potassium in the blood), when in fact the patient suffered from hyperkalemia (high potassium level). The facility is also unable to adequately assess and prevent patient falls. One patient fell a total of four times, breaking her ankle on the fourth fall. The only charted assessment and prevention plan was to, “advise the resident to use the call light” and to have physical therapy evaluate her for proper transfer technique. Her charting notes reflected that she had not yet been treated by any physical therapist.