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Operation Guardians Reports

Motion Picture and Television Fund Skilled Nursing Units – Woodland Hills


This facility’s atmosphere is described as chaotic and disorganized. An attending physician (who is also the medical director) “lacks basic medical knowledge concerning standards applicable to geriatric patients,” specifically the administration of medication. Physician charting notes lack meaningful evidence of the medical decision making process. Most residents are prescribed over ten medications, some even upwards of twenty. Medications are frequently administered solely to treat the side effects of other medications. One resident, before her death at the facility, had experienced a severe and extremely painful skin reaction to one of her numerous prescribed medications. Instead of discontinuing each medication one-by-one to determine which one caused the reaction, the patient was treated with topical ointment. According to the patient’s medical records, pain management was neglected.

The physician and nurse practitioner often treat patients without communicating. In one instance, the physician recommended an increase in the dosage of a medication that had been discontinued by the nurse practitioner. Painful morphine injections are administered to palliative patients whose pain medication could easily be administered orally. Two patients who had developed pressure ulcers were not adequately treated.

“Systemic problems…with extreme polypharmacy and the unwarranted prescription of psychoactive agents without adequate indications or consent…When residents reach the dying stage, care is definitely not in conformance with prevailing standards and residents are needlessly suffering as they die.”