LOS ANGELES, CA - Federal health inspectors documented serious medication safety violations at Skyline Healthcare Center, including staff crushing sustained-release drugs that could cause harmful immediate effects and failing to properly store critical medications like insulin.
Dangerous Medication Preparation Practices
The most alarming discovery occurred when inspectors observed a Licensed Vocational Nurse crushing Metoprolol Succinate ER tablets and opening Duloxetine DR capsules, mixing both with water for a resident receiving nutrition through a feeding tube. These medications are specifically designed as extended-release formulations that should never be crushed or opened.
According to manufacturer guidelines reviewed during the inspection, Metoprolol succinate ER tablets "should not be chewed or crushed," while Duloxetine DR capsules "should not be chewed or crushed" and opening the capsule "may affect how well Duloxetine DR capsules work."
The nurse who was observed preparing these medications acknowledged the serious nature of this error. "Sustained release medications such as the Metoprolol Succinate ER cannot be crushed, and Duloxetine DR capsule cannot be opened," the nurse stated. "Crushing the tablet or opening the capsule makes the release of the medication immediate instead of sustained."
Medical Risks of Improper Drug Preparation
When sustained-release medications are crushed or opened, the careful time-release mechanism is destroyed, causing the entire dose to be absorbed immediately rather than gradually over hours. This can lead to dangerous concentration spikes in the bloodstream.
For Metoprolol, a blood pressure medication, immediate release could cause dangerous drops in blood pressure or heart rate. Duloxetine, an antidepressant, when released all at once can cause severe gastrointestinal irritation, nausea, and other adverse effects.
The nurse explained that administering these medications as immediate release "will provide larger doses to Resident 295 at once resulting in more immediate side effects like gastrointestinal irritation."
Insulin Storage and Administration Failures
Inspectors also found multiple violations related to insulin storage and administration affecting diabetic residents. For one resident receiving insulin injections, staff failed to rotate injection sites as required, repeatedly administering insulin to the same location on the abdomen.
Medical records showed insulin was given to the same abdominal quadrant multiple times consecutively, violating manufacturer guidelines that require site rotation "to reduce risks of lipodystrophy and localized cutaneous amyloidosis."
Site rotation is critical for diabetes management because repeated injections in the same area can cause tissue changes that affect insulin absorption, leading to unpredictable blood sugar control.
Critical Storage Violations
The facility's medication storage practices posed additional risks to resident safety. Inspectors found multiple insulin pens stored improperly without required date labels, making it impossible to determine when they would expire and become ineffective.
Several insulin products were found stored at room temperature without documentation of when room temperature storage began. Manufacturer guidelines specify that opened insulin pens must be discarded after 28 days at room temperature, while unopened pens should remain refrigerated.
"Expired insulin has lost its effectiveness and administering expired insulin may result in Resident 6 to experience high blood sugar levels causing loss of consciousness, hospitalization, and death," a nurse explained during the inspection.
Infection Control Breakdown
The facility also failed to maintain basic infection prevention practices for respiratory equipment. Inspectors found nasal cannulas used for oxygen therapy that were not properly labeled with change dates, and observed staff placing contaminated tubing from the floor back into clean storage.
One nurse was seen picking up oxygen tubing that had fallen to the floor and placing it in a supposedly clean storage bag, creating contamination risk. "The dirty NC tubing could lead to respiratory infections," a registered nurse noted.
Suction equipment used for oral care was found unlabeled and improperly maintained, with canisters that should have been discarded after use still sitting on residents' nightstands.
Food Safety Concerns
The kitchen inspection revealed multiple food safety violations that could lead to foodborne illness among the facility's 86 residents. An unlabeled bag of shredded cabbage was found in the walk-in refrigerator without an opening date, making it impossible to determine freshness.
Inspectors observed unwashed measuring cups and spoons stored in an open bag, expired dishwasher test strips being used, and non-kitchen staff entering food preparation areas without proper hair restraints or hand washing.
Staff Training and Oversight Issues
The violations reveal systemic problems with staff training and supervision at the facility. Multiple nurses demonstrated lack of knowledge about basic medication safety principles, and supervisory staff failed to ensure proper procedures were followed.
The facility's Director of Nursing acknowledged that "pharmacists and several LVN's failed to clarify the Metoprolol Succinate ER and Duloxetine DR orders for alternate options" rather than attempting to crush unsuitable medications.
Industry Standards and Expectations
Current medical standards require nursing facilities to have robust medication management systems with multiple safeguards. The "five rights" of medication administration - right patient, right medication, right dose, right route, and right time - are fundamental safety principles that appeared to be compromised.
Professional nursing practice standards require that when oral medications cannot be safely crushed for feeding tube administration, alternative formulations must be obtained through the pharmacy or physician, not improvised through dangerous crushing of inappropriate drugs.
Regulatory Response and Implications
The Centers for Medicare & Medicaid Services inspection resulted in multiple deficiency citations that the facility must address through corrective action plans. These violations affect the facility's compliance with federal nursing home regulations and could impact its Medicare and Medicaid certification.
Residents and families have the right to expect that their medications will be administered safely according to medical standards. When facilities fail to meet these basic requirements, vulnerable populations face unnecessary health risks.
The inspection findings highlight the critical importance of proper medication management systems, staff training, and supervisory oversight in nursing facilities where residents depend on professional caregivers for their most basic health and safety needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2024-06-13 including all violations, facility responses, and corrective action plans.
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