A review of the drug regimens for 27 residents at Palos Verdes Health Care Center revealed inappropriate use of psychotropic drugs to control the behavior of many residents in the facility. – Fourteen residents were given psychotropic drugs for reasons other than to treat specific conditions. – Ten residents were given as needed (PRN) psychotropic drugs beyond the legal limit of 14 days. – Seven residents had duplicative psychotropic drugs, from the same pharmacological class, without a documented clinical rationale. – Twenty-one residents did not have timely gradual dose reduction attempts. – Ten residents did not have adequate monitoring for target behaviors and adverse effects. Psychotropic drugs were given to residents to make “it easier to provide care,” ensure residents “follow instructions better,” and make them “easier to talk to.” Some residents were given drugs to address their “sad face.” The facility had multiple breakdowns of the regulatory processes meant to protect against inappropriate drugging of residents, from physician oversight and pharmacy consultant services to nursing documentation and supervision. For these multiple violations affecting multiple residents, the facility was given one Class B citation and fined a paltry $2,000.

Download the pdf of this citation HERE.
Violation of the Month Archive