Licensed Nurse J found the exposed metal hardware during a wound evaluation on September 3. The hardware measured approximately 2.5 centimeters by 2 centimeters by 0.3 centimeters and protruded from Resident 35's right lateral ankle with no drainage noted.
The nurse documented the discovery but failed to immediately contact the facility's medical director or director of nursing as required by policy.
Instead, LN J called the resident's orthopedist office that day, but received no answer because it was late in the day. She then waited until September 5 to contact the facility's medical director about the exposed bone and hardware.
When the medical director learned of the condition on September 5, she immediately ordered the resident sent to a local hospital emergency room for evaluation. The orthopedic office had standing orders that any exposed hardware required emergency room evaluation.
Resident 35 told inspectors that LN J never mentioned exposed bone when explaining why she needed hospital treatment. "LN J told her she needed to go to a local acute care hospital on September 5 for right lateral ankle wound evaluation and treatment because there was a screw sticking out," the resident said during an interview on September 18.
The medical director expressed frustration during her interview with inspectors. She expected staff to notify her immediately of any change in a resident's condition, particularly something as serious as exposed bone and orthopedic hardware.
"MD stated she was not aware LN J documented the discovery of exposed bone and orthopedic screw during the wound evaluation and treatment on September 3," according to the inspection report. The doctor confirmed she should have been notified on September 3, not two days later.
During her interview with inspectors, LN J acknowledged her failures. She confirmed documenting the exposed bone on September 3 and admitted she should have contacted the medical director immediately rather than waiting for the orthopedist's office to return her call.
LN J also acknowledged failing to notify the director of nursing, another violation of facility policy. "LN J confirmed she did not notify the DON and should have," inspectors documented.
The director of nursing confirmed the policy violations during her own interview. She stated that LN J should have notified both her and the medical director immediately upon discovering the exposed bone and hardware.
The DON confirmed that September 5 was when the resident was finally sent to the hospital for wound evaluation, two days after the concerning condition was first documented.
The delay meant Resident 35 spent two additional days with exposed bone and orthopedic hardware before receiving appropriate medical evaluation. Federal inspectors classified the violation as having potential for actual harm to the resident.
LN J told inspectors she would notify the medical director immediately in future situations requiring urgent medical attention.
The violation occurred under federal regulations requiring nursing homes to ensure residents receive proper treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. The regulation also requires facilities to ensure that residents' abilities don't decline unless the decline is unavoidable due to the resident's clinical condition.
Exposed orthopedic hardware presents infection risks and requires immediate medical evaluation to prevent complications that could affect wound healing and the resident's overall condition.
The inspection was conducted in response to a complaint filed with state regulators about care at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Yuba City Post Acute from 2025-11-13 including all violations, facility responses, and corrective action plans.