RESEDA, CA - Federal inspectors found that Grancell Village of the Jewish Homes for the Aging administered antipsychotic medication to a resident with Alzheimer's disease without proper medical justification or monitoring, ignoring pharmacist warnings about inappropriate use.
Antipsychotic Given Without Clear Medical Indication
The January 16, 2025 inspection revealed that Resident 46, who had severe cognitive impairment from Alzheimer's disease, received Seroquel twice daily for what staff documented only as "agitation" - a vague term that failed to specify actual behaviors requiring medication.
The 25-milligram doses of Seroquel continued from January 1 through January 15, 2025, despite a consultant pharmacist's November 2024 warning that "mood disorder may not be viewed as an appropriate diagnosis" and that "agitation is too subjective" to justify antipsychotic use.
The Clinical Manager admitted to inspectors that the facility "forgot to act upon" the pharmacist's recommendation to review the medication's appropriateness. The manager acknowledged that agitation was "considered a subjective behavior and not an indication to administer Seroquel."
Critical Monitoring Order Discontinued, Never Reactivated
Making matters worse, the physician's order to monitor the resident's behaviors - described as "blowing raspberry in the air" - was discontinued on December 10, 2024, and never reactivated. This meant licensed nurses had not documented any behavior monitoring for over a month while the resident continued receiving the powerful antipsychotic drug.
The Director of Nursing confirmed that without defining specific behaviors, "monitoring for those behaviors cannot be objective as different nurses may document the behaviors for different reasons." She acknowledged that all psychotropic medications require appropriate diagnosis, clear indication for use, and measurable target behaviors for staff to monitor.
Medical Risks of Unmonitored Antipsychotic Use
Antipsychotic medications like Seroquel carry significant risks, particularly for elderly residents with dementia. These drugs can cause sedation, increased fall risk, metabolic changes, and cardiovascular effects. The FDA has issued black box warnings about increased mortality risk when antipsychotics are used in elderly patients with dementia-related psychosis.
Without proper monitoring of target behaviors, healthcare providers cannot determine if the medication is effective or if dosage adjustments are needed. This leaves residents exposed to potential side effects without clinical benefit. The Clinical Manager specifically noted that lack of monitoring results in "inability to measure the effectiveness of the medication and exposure of the resident to unwanted side effects."
Facility Policy Violations
The facility's own policies require that psychotropic drugs be used "only when necessary and then at the lowest effective dose" with "an appropriate diagnosis required for all psychotropic medications." The policy mandates that behaviors of residents receiving antipsychotics be monitored at appropriate intervals using behavior monitoring records.
The policy also requires that when a psychotropic medication order is found inappropriate, the Director of Nursing must be notified and the attending physician called for clarification. Despite the consultant pharmacist's November 2024 recommendation marked "Will Review," no action was taken for over two months.
Pattern of Oversight Failures
The inspection revealed systemic failures in the facility's medication management system. The consultant pharmacist performs monthly medication reviews as federally required, providing recommendations for medication therapy changes. The facility's policy states it "has a process to ensure that the findings are acted upon" - yet the Clinical Manager simply forgot to follow up on the pharmacist's concerns about inappropriate antipsychotic use.
The resident's care plan, initiated September 25, 2023, listed goals to reduce agitation episodes but failed to specify what constituted agitation or how to measure improvement. Interventions included administering Seroquel and monitoring effectiveness, yet staff could not articulate what behaviors they were supposed to monitor.
Additional Infection Control Violations
Inspectors also documented infection control failures that placed residents at risk. A nurse failed to wear a required gown while administering medication through a gastrostomy tube to a resident on Enhanced Barrier Precautions - protocols designed to prevent spread of drug-resistant organisms.
In another incident, oxygen tubing for a resident with heart failure and pulmonary hypertension was observed touching the floor. The CDC guidelines note that floors become rapidly contaminated from airborne microorganisms and substances transferred from shoes and equipment. A nurse confirmed the contaminated tubing could cause respiratory infection requiring hospitalization.
Regulatory Context
Federal regulations require nursing homes to ensure residents are free from unnecessary drugs and that psychotropic medications are used only when medically necessary with proper monitoring. Facilities must have systems to identify and respond to medication-related problems identified during required monthly pharmacy reviews.
The violations at Grancell Village demonstrate breakdown at multiple levels - from initial prescribing without clear indication, to failure to establish measurable monitoring parameters, to ignoring pharmacist recommendations, to allowing monitoring orders to lapse without correction.
For families with loved ones in nursing homes, these findings underscore the importance of asking specific questions about any psychotropic medications: What specific behaviors are being treated? How are those behaviors being measured and documented? What non-pharmacological interventions have been tried? Regular review of medication administration records and pharmacy consultant notes can help identify potential problems before they persist for months.
The full inspection report provides additional details about the facility's corrective action plan and timeline for addressing these deficiencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grancell Village of the Jewish Homes For the Aging from 2025-01-16 including all violations, facility responses, and corrective action plans.
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