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Operation Guardians Reports

Sunrise Convalescent Hospital – Pasadena


During an inspection of this facility, investigators found that decision making for residents with questionable capacity was confusing. “Several other residents did not have the capacity to make decisions and the facility staff had become their decision maker.” In addition, some residents who had been appointed conservators had personally signed forms consenting to the administration of medication without the conservator ever being notified. “In a number of cases reviewed, residents lacking capacity were signing their own POLST forms.” Additionally, the wishes of patients reflected in their POLST (Physician Orders for Life-Sustaining Treatment) forms, were sometimes ignored.

In one instance, one week prior to the death of a resident, nurses reported a malfunction in the resident’s gastronomy tube. The problem was never raised with the resident’s physician. A week later, one of the nurses reported that the resident had been vomiting a black and tarry substance. The patient’s POLST form indicated that she wished for life-sustaining treatment to be administered no matter the situation. The patient was never treated or taken to the hospital, and died hours after the resident’s vomiting had been recorded.

Some residents reported to investigators that on occasion their medication had not been timely administered, and several personal items had either been lost or stolen from the facility. Many residents also complained that the temperature in the facility was too cold, and several resident beds did not even have blankets.

One of the most prominent discoveries inspectors made at this facility was the lack of precautionary measures for residents wandering in and out of the facility. Residents were permitted on many occasions to come and go as they please without first informing staff. There had been reported incidents of elopements that the inspectors had been aware of prior to their visit to this facility, but no documentation for those incidents could be found in the facility’s medical records.

One resident recovering from a traumatic brain injury had suffered “small brain hemorrhaging” after falling at the facility one week prior to his being prescribed a tranquilizing medication. A side effect of the prescribed medication increased his chance of falling again. No precautionary measures to prevent a fall were taken with this resident, in fact, the resident was reported to have left the facility on at least one occasion without permission and returned with alcohol on his breath.