SEO_DESCRIPTION: Cottage Crest Post Acute in Norwalk cited for dangerous 48.78% medication error rate affecting critical blood pressure, heart, and anti-clotting medications.
OG_TITLE: Cottage Crest Nursing Home: Nearly 50% Medication Error Rate Triggers Emergency Action
OG_DESCRIPTION: Federal inspectors found a shocking 48.78% medication error rate at Cottage Crest Post Acute in Norwalk, CA, with critical medications for blood pressure, heart conditions, and blood clots being missed or administered improperly, creating immediate jeopardy.
FB_POST: Nearly 50% medication error rate at Norwalk nursing home triggers immediate jeopardy - critical heart meds missed
ARTICLE:
Cottage Crest Post Acute: 48.78% Medication Error Rate - CA
NORWALK, CA - Federal inspectors declared an immediate jeopardy situation at Cottage Crest Post Acute after discovering a staggering 48.78% medication error rate during a June 2024 inspection.
Critical Medication Failures Endanger Residents
The California Department of Public Health found 20 medication errors out of 41 medication administration opportunities, affecting five residents who required critical medications for blood pressure, heart conditions, infection treatment, and blood clot prevention.
The most serious violations included omitting blood pressure medications when residents' readings exceeded safe parameters, attempting to administer heart medications when vital signs indicated they should be withheld, and failing to provide antibiotics for infections.
Resident 26 did not receive Metoprolol Tartrate for blood pressure control and was denied Clonidine when blood pressure reached 153/52, exceeding the 150 threshold requiring medication administration.
Resident 209 faced multiple medication omissions, including Apixaban for blood clot prevention, Potassium Chloride for heart function, and Lactobacillus for digestive health. Staff also attempted to administer blood pressure medications when the resident's pressure was dangerously low at 97/41.
Improper G-Tube Administration Techniques
Inspectors documented serious violations in gastrostomy tube medication administration for Resident 19. The facility administered ten different medications using improper techniques that violated physician orders and medical standards.
Licensed staff pushed medications through the feeding tube using syringe pressure instead of allowing gravity to naturally carry medications into the stomach. This technique increases risks of tube dislodgement, aspiration, and medication delivery complications.
The resident also received the wrong type of multivitamin - receiving one with minerals when only plain multivitamins were ordered. Staff failed to provide the required five milliliters of water between each medication as prescribed.
Missing Medications Create Treatment Gaps
Multiple residents experienced treatment interruptions due to medication shortages. Resident 211 went without Amoxicillin antibiotic treatment for an ear infection, while Resident 210 missed topical Lidocaine cream for arthritis pain management.
The facility's medication reordering system failed to maintain adequate supplies, with some medications running out before replacements arrived. Staff admitted to not calling physicians or pharmacies when medications became unavailable.
Medical Consequences and Risk Factors
The medication errors created significant health risks across multiple body systems. Blood pressure medication omissions can lead to hypertensive crises, stroke, and cardiovascular complications. Missing blood thinning medications increases risks of dangerous blood clots, potentially causing pulmonary embolism or stroke.
Improper G-tube techniques can cause feeding tube displacement, requiring emergency medical intervention. When feeding tubes become dislodged, residents may need surgical replacement and face risks of aspiration pneumonia.
Antibiotic interruptions allow infections to persist and potentially worsen, leading to systemic complications requiring hospitalization.
Industry Standards for Medication Management
Nursing homes must maintain medication error rates below five percent according to federal regulations. The facility's 48.78% error rate represents a nearly ten-fold increase above acceptable standards.
Standard medication administration protocols require nurses to check vital signs before giving blood pressure medications and hold doses when parameters fall outside prescribed ranges. Licensed staff must follow the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time.
Proper G-tube administration requires gravity-fed delivery to prevent complications. Medications should flow naturally down the tube, with water flushes between different medications to prevent interactions and ensure complete delivery.
Facility Response and Corrective Actions
Following the immediate jeopardy declaration on June 6, 2024, Cottage Crest implemented comprehensive corrective measures. The facility conducted medication reconciliation for all affected residents and ordered missing medications for immediate delivery.
Twenty-one licensed nurses received mandatory re-education on medication administration, documentation, and availability protocols. Staff who failed competency assessments were prohibited from administering medications until successfully completing retraining.
The facility established weekly medication cart audits and implemented a Quality Assurance Performance Improvement project to monitor medication practices for three months.
Emergency Measures Remove Immediate Jeopardy
California health officials removed the immediate jeopardy designation on June 8, 2024, after verifying implementation of corrective actions. All affected residents underwent medical assessments to monitor for complications from medication errors.
Resident 26 was evaluated for signs of cardiovascular complications from missing blood pressure medications. Resident 209 received assessment for potential effects from omitted heart and blood-thinning medications.
The facility's Regional Nurse Consultant provided direct oversight of medication administration practices and observed licensed staff to ensure compliance with proper procedures.
Ongoing Monitoring and Compliance
The violations highlight systemic failures in medication management that required comprehensive organizational changes. Federal regulations mandate that nursing homes maintain adequate medication supplies and follow physician orders precisely.
Facilities must implement systems to prevent medication shortages and ensure staff competency in administration techniques. Regular audits and quality assurance programs help identify potential problems before they reach crisis levels.
The immediate jeopardy classification reflects the severity of medication errors and their potential to cause serious harm or death. Such designations require immediate corrective action and ongoing monitoring to ensure sustained compliance.
Cottage Crest Post Acute must demonstrate continued adherence to medication safety protocols to maintain federal certification and avoid additional regulatory sanctions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cottage Crest Post Acute from 2024-06-11 including all violations, facility responses, and corrective action plans.
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