The Skilled Nursing Facility Conditions Inside a California State Prison Infirmary
The Paris Lamb Treatment Center is a Skilled Nursing Facility (SNF) located at the Central California Women’s Facility (CCWF). It functions as an on-sight prison infirmary that houses prisoners too ill to live in general population, those patients pre and post-operative, individuals with special dietary needs (which aren’t allowed in general population) and prisoners with ambulatory impairment. The Department of Health Services (DHS) functions as the oversight agency responsible for ensuring that the SNF adheres to the laws set out in Title 22 relating to the operation of these types of health-care facility. Between April 1999 and July 2000, the DHS received at least five complaints regarding the care given at the SNF at CCWF. Each complaint filed required an on-site investigation of the SNF. Specific Findings:
• On October 4, 1999, a patient was admitted to the SNF from the Emergency Room with signs and
symptoms of end stage liver disease. “The facility failed to identify the care needs and implement a plan of care at the time of admission.” A physician’s order was noted for 3:00 p.m. for an ammonia level to be drawn “now.” An ammonia level was drawn at 9:48 p.m. The results were reported two days later. There was no care plan in the medical records when received. In fact, no care plan was initiated until October 7th, when the woman was taken to the acute hospital. She died that evening. The ammonia level drawn on admission to the hospital was 20.12, which is up to 100 times higher that normal (.17 - .80).
• One patient was admitted to the facility with an open wound. There was a physician’s order,
dated January 31, 2000, to treat the wound daily. The record indicated that no treatment was done in the following two days.
• Meals for the mental health patients were served on a styrofoam plate with a styrofoam cover.
The patients were not given utensils, instead the staff stated that “patients usually tear off the styrofoam to pick up the food and place it in their mouth.”
• One patient was given a lab test for levels of Dilantin, an anti-seizure medication. The results
indicated that her Dilantin level was toxic. There is no indication that the nursing staff notified the physician until a day later.
• In 17 of 18 patients sampled the facility failed to keep medical records in detail consistent with
• In some instances patients’ medical orders were not carried out as specified, including lab tests,
wound treatment and monitoring of vital signs.
• The facility failed to provide one patient with an adequate quantity or quality of food. The facility
also failed to provide therapeutic diets as prescribed.
• Prescription drugs were left unguarded and accessible to patients and non-designated personnel.
Prescriptions were recorded and documented incorrectly. When these deficiencies resulted in missing medications, no reports or follow up was completed.
• In some instances the facility failed to identify care needs, implement a care plan, and/or follow
Regarding Personal Hygiene: The DHS investigation found that “the residents had dirty gowns on with food stains and were not in good repair. The residents had foul body odors. Their hair was uncombed and looked dirty. The fingernails of the residents were long with dirt under the nails. None of the residents appeared to have had oral care for a long period of time.” Representatives concluded that, “based on observation and interview of residents and staff, the facility failed to treat each patient as an individual with dignity and respect, or to provide care which shows evidence of good personal hygiene and to provide privacy during treatments.” Proposed Solution: To ensure that the SNF continually follows the law with regards to the maintenance and operation of the Paris Lamb Treatment Center, legislation should be passed that would require the DHS to conduct a full scale investigation at least every two years. 1540 Market St., Suite 490 San Francisco, CA 94102 (p) 415-255-7036 (f) 415-552-3150 www.prisonerswithchildren.org | email@example.com
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