Attorney General Lockyer Issues Report on First Year of Surprise Nursing Home Inspections

Operation Guardians Making a Difference, Prompting Nursing Home Improvements

Tuesday, April 17, 2001
Contact: (916) 210-6000,

(LOS ANGELES) – Attorney General Bill Lockyer today issued a report on Operation Guardians, a multi-agency task force which in its first year of surprise inspections has triggered improvements in the quality of care and living conditions in over two dozen nursing homes in southern California.

"Encouraging first-year results show Operation Guardians prompting improvements after each surprise inspection," Lockyer said. "For elderly and dependent Californians in these facilities, this means rundown and unsafe nursing home buildings are being fixed, improvements are being made in the quality of care they receive and renewed attention is being given to their dignity. At the same time, major problems have been referred for further investigation and possible enforcement actions."

The Attorney General's report, "Operation Guardians - 2001 Annual Report," covers 50 inspections, including 28 in southern California, between April 2000 and March 2001. Results of the task force inspections ranged from near-complete compliance to problems significant enough to be referred to law enforcement or regulatory and/or licensing agencies. Surprise nursing home inspections were conducted in the counties of Alameda, Fresno, Los Angeles, Monterey, Napa, Riverside, Sacramento, San Bernardino, San Diego, Santa Barbara, Santa Clara and Ventura.

"While there is much more to be done, Operation Guardians is a valuable tool in the fight against elder abuse and in ensuring that nursing homes take seriously their responsibilities for compassionate and quality care for elderly Californians," Lockyer said. "We are looking to more surprise inspections by Operation Guardians and expanding to other parts of the state."

The problems found by Operation Guardians fell generally into five categories:

Environmental Non-compliance. Of the 50 inspections completed, 48 (27 in southern California) found compliance problems based on substandard maintenance of the grounds or buildings, which in varying degrees violated the nursing home's responsibility to provide a habitable, safe and livable environment for residents. Problems included foul odors from urine; unsafe handrails; mildew; hazardous walking surfaces; infestations by roaches, other bugs and rodents; and dilapidated living quarters.

Patient Care Non-compliance. Of the 50 inspections completed, 41 (21 in southern California) found compliance problems relating to patient care, such as failure to keep adequate patient charts, poor maintenance of emergency medical equipment, unsafe storage of prescription drugs, malfunctioning call lights or non-response to patients seeking attention using call lights; medical staff failing to make required rounds to visit patients; and preventable injuries and health problems.

Administrative Non-compliance. Of the 50 inspections completed, 27 (12 in southern California) found compliance problems relating to oversight of personnel matters, patient trust accounts and other administrative responsibilities, such as personnel files failing to contain up-to-date licensing information on care givers; poor accounting practices; missing patient identification tags; and improperly maintained patient discharge records.

Fire Safety Violations. Of the 50 inspections completed, 17 (nine in southern California) found violations of local fire safety ordinances that if left unabated could result in serious harm or death, such as unsafe chemical storage; inoperative fire extinguishers; inoperable fire alarms; obstructed fire exits; exposed wiring; and improperly operating fire doors.

Staffing Level Non-compliance. Of the 50 inspections completed, five (three in southern California) found compliance problems with state and federal laws governing proper staffing levels for skilled nursing home facilities. State law requires at a minimum 3.2 hours of nursing care (Certified Nursing Assistants, Licensed Vocational Nurses, Registered Nurses or other appropriately certified staff) per patient per day. Federal regulations require staffing levels to be adequate to care for all patient needs "to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident."

Operation Guardians is a cooperative effort of the Attorney General's Bureau of Medi-Cal Fraud and Elder Abuse; local district attorneys, local fire departments and the federal Office of Inspector General, US Department of Health and Human Services. Also part of the team are the University of Southern California School of Medicine, UCLA School of Medicine, and the Medical Board of California.

In the operation, state investigators, local fire marshals, code enforcement officials and patient-care specialists make unannounced visits to nursing homes selected randomly by the Attorney Genearl's Bureau of Medi-Cal Fraud and Elder Abuse. Local inspectors review physical structures for sanitation, safety and fire hazards, while health experts help detect any abuse and neglect of nursing home residents. State and local prosecutors are available to bring criminal action if warranted. Health quality violations are referred to the state Department of Health Services (DHS). These surprise inspections complement the regular inspections required to be conducted no less than every 15 months by DHS, which is responsible for licensing and regulating the state's approximately 1,500 skilled nursing home facilities.

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PDF icon 01_037.pdf4.2 MB