This is a summary of the just released California Department Of Public Health inspection of the Motion Picture & Television Fund’s skilled nursing facility completed on June 4, 2010. The advocacy group Saving The Lives Of Our Own, which has been fighting the closing of the long-term care hospital and nursing home, compiled this summary and also has posted the full report here:

Illegal Transfers

After announcing its plan to close the facility, the Motion Picture Home moved dozens of its residents to other facilities without notifying any of the residents of their transfer and discharge rights – including their right to appeal the transfers – in violation of California and federal laws. The Home also failed to comply with its own relocation plan, which required it to provide 30 days advance written notice to residents and their representatives prior to any transfers initiated pursuant to the closure.

According to CDPH’s report, the Motion Picture Home’s Director of Social Services and Vice-President of Professional Services admitted that none of the transferred residents were notified of their rights. Prior to closure, California law requires nursing homes to develop and implement relocation plans in order to protect elderly residents from transfer trauma. (Note: Many of the transferred residents have since died.)

Severe Weight Loss

Inspectors found that at least three residents suffered severe weight loss without adequate response by the Motion Picture Home. (Note: Inspectors surveyed a sample of 16 out of a total of 80 skilled nursing residents.)

One resident’s weight dropped from 126 pounds in November 2009 to 108 pounds in May 2010, a severe 13.6 percent weight loss. Most of the resident’s weight loss occurred between April and May 2010 after he suffered multiple falls and fractures. The Motion Picture Home did not revise his nutrition care plan to address the actual weight loss or to provide interventions to prevent future weight loss.

Another resident suffered a severe weight loss, dropping from 140 pounds in April 2010 to 122 pounds in May 2010 after she fractured her hip in a fall she suffered at the facility on March 27, 2010. The resident subsequently died.

A third resident suffered severe weight loss when her weight dropped from 130 pounds in December 2009 to 123 pounds in January 2010, a seven-pound weight loss (5.4 percent) in one month.

Avoidable Injuries

Two of the residents described above suffered falls and fractures at the Motion Picture Home without adequate response by the facility.

One resident suffered seven (7) falls between February 3, 2010 and May 17, 2010, with most of the falls occurring during early morning hours when he was alone with no staff present. The last two falls resulted in fractures and significant loss of independence. On March 30, 2010, he was found on the floor of the shower room. He suffered a pelvic ring fracture but it was not discovered for almost a month despite the resident’s constant complaints of pain in his back and leg. On May 17, 2010, he was found on the floor of his room complaining of severe shoulder pain that was caused by a fractured shoulder. As a result of the injuries, the resident lost his ability to walk and required extensive assistance with personal needs. The Motion Picture Home did not update his care plan or update his fall risk assessment after the many falls.

As noted above, one resident suffered severe weight loss and later died after she fell and fractured her hip at the facility on March 27, 2010. The fall occurred at 5:30 am. Despite its policy to update residents’ care plans as frequently as needed, the Motion Picture Home failed to revise her care plan to address falls after she suffered this life-threatening injury.

Unnecessary Drugs

The Motion Picture Home violated federal regulations that prohibit the use of unnecessary drugs. At least three residents were given large numbers of drugs, including sedatives and psychoactive medications, without justification. In one case, a resident received seven (7) different medications without adequate indications. Another resident was given eight (8) different medications without adequate indications. A third resident was given twenty-five (25) different medications in a one-week period, including hypnotic drugs.

Other Findings

The inspectors also cited the Motion Picture Home for failing to give appropriate services to help a resident maintain her ability to walk, failing to report a resident’s injuries of unknown origin to CDPH as required, unnecessary cathererization of a resident, unsanitary food practices, an unsafe environment (damaged electrical receptacle), and incomplete medical records.

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