Politics & Government

Operation Guardians Reports Show 'Rampant Abuse and Neglect' at Local Nursing Home

The facility is identifying and correcting areas management believes need improvement.

A state Department of Justice program report made public Tuesday has found a Tarzana elder care facility to have substandard physician services and problems with polypharmacy and end-of-life care.

According to report made by Operation Guardians, a state program that conducts surprise inspections at nursing homes, Tarzana Health and Rehabilitation Center also has deficient nursing care and monitoring. The Operations team visited and filed its report in April of this year.

After Operation Guardians inspections are completed, evaluations of facilities’ quality of care and basic sanitation are filed. Each inspection generally generates two reports, one by the inspection team as a whole that assesses the general sanitation and care provided by the facility staff and a medical report written by a medical doctor who specializes in geriatrics. Care facilities are then given the opportunity to file a response for the public record.

Find out what's happening in Encino-Tarzanawith free, real-time updates from Patch.

The reports are not generally made available to the public; however, the California Advocates for Nursing Home Residents, or CANHR, made a Public Records Act request to obtain all reports issued from January 1, 2010 through March 7 of this year and has subsequently posted the 14 reports it received to its website. Among the 14 sites inspected is also the Motion Picture and Television Fund's Skilled Nursing home in Woodland Hills.

In a written statement to Patch, Annaliese Impink, spokesperson for Tarzana Health and Rehabilitation Center, said while the facility’s management does not necessarily agree with all of the findings in the state’s report, it does take all reports which identify concerns seriously.

Find out what's happening in Encino-Tarzanawith free, real-time updates from Patch.

“The facility has reviewed the report and, where necessary, taken appropriate steps to address and correct the areas identified,” she wrote.

The state’s inspecting physician, Kathryn Locatell, found that though the timeliness and frequency of visits by medical providers conform to standards for the most part, the care being provided does not.

“These providers are using excessive numbers of medications and invasive therapies without appropriate indications and without adequate monitoring by either the provider or the facility’s nursing staff,” she reported.

Locatell sites the case of a 90-year old diabetic patient who’s been prescribed twice-daily injections of long-acting insulin, a medication considered high risk to older people. Locatell reported the patient’s blood sugar level was in the low range and she may have been getting too much insulin.

“The physician, however, had increased her insulin does in January 2012 despite that fact, and the fact that (the resident) had a life-threateningly low blood sugar level just six days earlier,” Locatell found.

The inspecting physician also found the center to not be providing palliative and end-of-life care in conformance with residents’ stated directives and current standards.

For example, she found physicians appeared to be ordering intravenous fluid therapy for a patient whose advance directive indicated she was to receive comfort measures only. As a consequence of the intravenous fluids, the resident developed considerable swelling that nurses judged uncomfortable for the resident, the report said.

The report also found “in general, the medical providers’ practice pattern is that of polypharmacy (the use of multiple drugs by a patient), they order excessive laboratory tests and IV therapy, and fail to define goals of care or consider risks and benefits to the resident.”

The team report also indicated concerns with incomplete records, missing equipment (specifically a patient’s specially-fitted wheelchair), charging a patient with physical therapy treatment that, according to her chart, she had refused and some administrative observations.

According to Impink of the rehabilitation center, “Management continues to monitor the corrective action to assure that we continue to provide quality care and services to the individuals we have the privilege to serve everyday.”

The California Advocates for Nursing Home Residents executive director, Pat McGinnis, called the Operation Guardians a valuable program in uncovering instances of elder abuse and neglect, but the organization finds fault with the program in two regards.

First, though reports are shared with the Department of Public Health for follow up and investigation, DPH has taken little subsequent enforcement action, the organization said in a statement issued Tuesday.

In the case of the Motion Picture hospital, McGinnis said her organization reviewed all of the available records for the facility six months up to the current date after the attorney general’s report and there are no files on the Department of Public Health’s website regarding it. She noted there was a citation issued to the facility in 2011 for patient care, but that would have been issued prior to this year’s March report.

“Since no other enforcement action has occurred, it is assumed that no enforcement actions have happened as a result of the report,” McGinnis said.

In fact, she said, as far as her group could determine, no enforcement action has been taken in regards to any of the 14 inspections and reports filed between Jan. 1, 2010 and March 7 of this year.

Calls to the Department of Justice by Patch were not returned.

The other problem CANHR sees with the Operation Guardians program is that its reports are not made public.

"Its findings are completely unknown to nursing home residents and their families," said McGinnis in a written statement. "We’re pleased to be able to publicize this information so residents and their loved ones can be better informed when choosing a nursing home.”

To read the Operation Guardian report of the Motion Picture and Television Fund hospital, visit the CANHR website here.

For a list of all 14 reports, visit the CANHR website here.


Get more local news delivered straight to your inbox. Sign up for free Patch newsletters and alerts.

We’ve removed the ability to reply as we work to make improvements. Learn more here

More from Encino-Tarzana