PASADENA, CA - A resident at Pasadena Palace TCU was hospitalized in intensive care after overdosing on unprescribed medications and alcohol that facility staff failed to detect or confiscate.
Critical Safety Failures Lead to Life-Threatening Overdose
The May 2025 incident involved a cognitively intact resident with diagnosed depression, anxiety, and borderline personality disorder who was found unresponsive on May 12 at 5:20 AM. The resident had consumed multiple prescription medications obtained from an outside pharmacy along with wine, resulting in hospitalization with a Glasgow Coma Scale score of 3 - indicating deep unconsciousness.
Licensed Vocational Nurse LVN 1 discovered the resident "laying across the bed horizontally and snoring loud" with two opened prescription containers of doxepin and one bottle of ondansetron on the bedside table. The medications were labeled with the resident's name but came from an outside pharmacy, violating facility policies.
Emergency medical services transported the resident to a general acute care hospital where medical staff immediately intubated the patient due to poor neurological responsiveness. Hospital records confirmed an intentional tricyclic antidepressant overdose, possibly combined with Klonopin and alcohol.
Contraband Medications and Alcohol Discovery
Police investigation revealed the extent of prohibited substances the resident had accumulated within the facility. Officers found eight medication bottles in the resident's belongings, including:
- Multiple bottles of Klonopin (anti-anxiety medication) - Several containers of doxepin (antidepressant) - Ondansetron (anti-nausea medication) - A 1.5-liter bottle of wine purchased three days prior
Several medication containers were found empty, suggesting previous consumption. The facility's investigation also uncovered 15 pieces of Dilaudid, 52 capsules of doxepin, and other medications, some expired since 2020.
The resident had purchased the wine from a pharmacy on May 9, keeping the receipt in a shopping bag alongside the medication bottles. This timeline indicates the resident had been planning and accumulating these substances for days without staff detection.
Missed Warning Signs and Inadequate Monitoring
Two weeks before the overdose, on April 28, the resident had been assessed as "danger to self and others" and ordered for psychiatric hospital transfer. However, the resident refused the transfer, and facility staff failed to implement required safety protocols.
Progress notes from April 28 documented the resident stating the facility "should have been burned down in the fire so all of us suffering from this could have somewhere better." Despite these concerning statements and the formal danger assessment, no enhanced monitoring or safety interventions were implemented.
The facility also failed to provide adequate follow-up when the resident refused psychiatric consultation on May 8. Staff made no additional attempts to arrange mental health evaluation or implement alternative safety measures.
Medical Consequences and Treatment
The resident's condition upon hospital admission was critical. A Glasgow Coma Scale score of 3 represents the lowest possible level of consciousness, typically indicating severe brain dysfunction. The score ranges from 3 (deep coma) to 15 (fully conscious).
Medical staff immediately intubated the resident to protect the airway and assist breathing. The patient required intensive care monitoring from May 12 to May 14 before being stable enough for transfer to a medical-surgical unit.
Tricyclic antidepressant overdoses can cause dangerous heart rhythm abnormalities, seizures, and respiratory depression. When combined with alcohol and benzodiazepines like Klonopin, the sedative effects are dramatically amplified, creating life-threatening central nervous system depression.
Immediate Jeopardy Designation and Response
California health officials declared an "immediate jeopardy" situation on May 14, determining that facility failures had caused or were likely to cause serious injury, harm, or death to residents. This designation represents the most serious level of regulatory concern.
The facility submitted an acceptable corrective action plan on May 16, which included:
Enhanced monitoring protocols requiring hourly behavioral observations for at-risk residents and immediate physician notification for treatment refusals.
Comprehensive assessments of all residents with depression, anxiety, or borderline personality disorder to identify additional safety risks.
Crisis intervention procedures including one-to-one supervision when necessary and specialized care plans for residents identified as dangerous to themselves or others.
Staff education on recognizing psychiatric emergencies, proper documentation requirements, and communication protocols for changes in resident condition.
Systemic Policy Violations
The facility's own policies clearly prohibited outside medications and alcohol. The restricted items policy, revised in March 2016, specifically identified "drugs/medications not prescribed by facility physicians" and "alcohol and items containing significant amounts of alcohol" as contraband.
The policy required all staff to observe the environment for potentially unsafe items and authorized searches based on reasonable suspicion. However, staff interviews revealed inconsistent implementation of these safety protocols.
One nurse stated they "do not check residents' belongings" and that "residents usually present whatever they have." This approach clearly failed to protect vulnerable residents from harmful substances.
Industry Standards and Best Practices
Nursing facilities must maintain comprehensive medication management systems to ensure resident safety. All medications should be reviewed by facility physicians, dispensed through contracted pharmacies, and stored securely to prevent unauthorized access.
For residents with mental health conditions, facilities must provide appropriate psychiatric services, implement individualized care plans, and maintain enhanced monitoring when safety risks are identified. When residents refuse recommended treatments, alternative interventions must be developed to ensure continued safety.
The facility's contraband policy reflected industry standards, but implementation failures created dangerous gaps in resident protection. Regular room inspections, staff training on contraband identification, and clear protocols for handling treatment refusals are essential components of resident safety programs.
Ongoing Monitoring and Compliance
The facility's corrective action plan established ongoing monitoring requirements, including weekly audits of residents with behavioral risks for four weeks, followed by monthly reviews for three months. All refusals of psychiatric care or hospital transfers must be reviewed by the interdisciplinary team within 24 hours.
The administrator acknowledged the facility "failed to assess, supervise and monitor" the at-risk resident, directly contributing to the life-threatening overdose incident. This case demonstrates the critical importance of consistent policy implementation and staff vigilance in protecting vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Palace Tcu from 2025-05-16 including all violations, facility responses, and corrective action plans.
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