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Operation Guardians Reports

Tarzana Health and Rehabilitation Center – Tarzana


“Providers (at this facility) are using excessive numbers of medications and invasive therapies, without appropriate indications and without adequate monitoring.” This facility administers medication including antipsychotics without a legitimate medical basis to do so. For example, one quadriplegic resident who had not been evaluated or examined by a physician since his admission to the facility a month prior to the inspection, was treated with depakote for depression, but his chart lacked any such diagnosis. He also did not have access to his specialized electric wheelchair, rendering him bed-ridden.

Another resident suffering from unsteady balance, who had fallen several times prior to her admission into the facility, was treated with an antipsychotic drug, the side effect of which doubled the risk of falling. There was similarly no diagnosis nor information in her chart which would justify the drug’s administration.

One resident’s chart reflected that her blood sugar levels had fallen to life-threatening levels. Despite the fact that the low blood sugar may have resulted from the over-administration of insulin, her physician ordered her dosage be increased. “It was strongly recommended that [administrator and director of nurses] enlist the assistance of the facility’s medical director in addressing the inadequate quality of care by medical providers.”