PASADENA, CA - State health inspectors documented significant medication management violations at Pasadena Care Center during a June 2024 inspection, finding that staff failed to administer critical medications on time and did not properly follow up on pharmacy safety recommendations.
Critical Medication Administration Failures
During the inspection, surveyors identified serious medication administration errors affecting a resident with multiple serious health conditions. On the morning of June 14, 2024, a Licensed Vocational Nurse failed to provide six essential medications to a resident diagnosed with seizures, high blood pressure, and brain cancer.
The missed medications included Levetiracetam, a critical anti-seizure medication prescribed at 750 mg twice daily. Inspectors also documented the failure to administer three blood pressure medications: Cozaar 50 mg, Norvasc 5 mg, and Lasix 20 mg. Additionally, the resident did not receive Docusate Sodium for bowel management and a Lidocaine patch for pain relief.
During observation at 8:56 AM, the nurse prepared only five medications for the resident instead of the required eleven. When questioned at 10:55 AM, the nurse acknowledged the medication errors. A Registered Nurse confirmed these failures during a subsequent interview, stating that "missed blood pressure medications might lead to uncontrolled high blood pressure" and that a "resident who was not given Levetiracetam might have seizure."
The facility's own Licensed Vocational Nurse acknowledged that "failing to administer medication to a resident per the physician's order can lead to medical complications possibly resulting in hospitalization."
Medical Consequences of Medication Errors
These medication failures created immediate health risks for the affected resident. Anti-seizure medications like Levetiracetam require consistent blood levels to prevent breakthrough seizures. Missing doses can lead to seizure activity, which poses serious risks including injury from falls, respiratory distress, and potential brain damage.
The failure to administer multiple blood pressure medications simultaneously compounds cardiovascular risks. Cozaar, Norvasc, and Lasix work through different mechanisms to control blood pressure and manage fluid retention. Missing these medications can result in dangerous blood pressure spikes, increased strain on the heart, and worsening of existing heart conditions.
Pain management medications require consistent administration to maintain therapeutic levels. The missed Lidocaine patch meant the resident experienced unnecessary discomfort, which can impact sleep, mobility, and overall quality of life.
Improper Medication Timing
Beyond missed medications, inspectors found timing violations with Dexamethasone, a critical anti-inflammatory medication prescribed for the resident's brain cancer. The medication was ordered to be given every eight hours at 6 AM, 2 PM, and 10 PM. However, staff administered the 2 PM dose at 9:18 AM instead, disrupting the therapeutic schedule.
Dexamethasone timing is particularly important for cancer patients because it helps reduce brain swelling and inflammation around tumors. Irregular dosing can lead to inadequate symptom control and potential complications from increased intracranial pressure.
Pharmacy Review System Failures
Inspectors also identified failures in the facility's pharmacy oversight system. The facility failed to follow up on critical recommendations from their consulting pharmacist's May 2024 medication review for two residents.
For one resident, the pharmacist recommended evaluating whether two similar heart medications - Vascazen and Vascepa - should both be prescribed, as they have overlapping effects. For another resident, the pharmacist questioned the prescription of Zyprexa 10 mg three times daily, requesting verification of the diagnosis and specific behavioral symptoms requiring this psychiatric medication.
The Director of Nursing acknowledged that the facility "did not follow up the MRR [Medication Regimen Review] for the month of May in timely manner" and only contacted the pharmacist consultant on June 10, 2024, nearly two weeks after receiving the recommendations.
Industry Standards and Medication Safety
Federal regulations require nursing homes to maintain comprehensive medication management systems with multiple safety checks. Medications must be administered according to physician orders, including specific timing requirements. The facility's own policies, revised as recently as April 2024, state that "medications are administered in a safe and timely manner, and as prescribed" and "in accordance with prescriber orders, including any required time frame."
Monthly pharmacy reviews serve as a critical safety net to identify potentially harmful drug interactions, inappropriate medications, or dosing errors. These reviews must be promptly evaluated and recommendations communicated to prescribing physicians. The consulting pharmacist emphasized the importance of her recommendations, stating her goal was "to make sure resident was not receiving medications with the same effect" and to "verify the diagnosis and specific target behavior" for psychiatric medications.
Additional Issues Identified
The inspection revealed broader medication management concerns beyond the specific incidents documented. The facility's medication error rate exceeded acceptable standards, indicating systemic problems with medication safety protocols. Staff training and supervision appeared inadequate given the nature and extent of the errors observed.
The violations suggest gaps in the facility's quality assurance processes, particularly in medication administration oversight and pharmacy consultation follow-up procedures. These systemic issues raise concerns about medication safety for all residents, not just those specifically documented in the violations.
The facility's failure to implement timely responses to pharmacy recommendations could result in residents receiving unnecessary medications or missing opportunities to optimize their medication regimens for better health outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Care Center, LLC from 2024-06-14 including all violations, facility responses, and corrective action plans.
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