San Bruno Skilled Nursing: 11% Medication Error Rate - CA
SAN BRUNO, CA - Federal inspectors documented a concerning medication error rate of 11% at San Bruno Skilled Nursing during a June 2024 inspection, more than double the acceptable 5% threshold established for resident safety.
Critical Medication Administration Failures
The dangerous error rate emerged from observations of 26 medication administration opportunities involving multiple residents on June 11, 2024. Inspectors documented three separate medication errors that demonstrated systemic failures in basic safety protocols.
The first error involved complete failure to verify patient identity before medication administration. A registered nurse attempted to confirm the identity of Resident 10 by asking for her name, but when the resident could not respond in English, the nurse proceeded without seeking alternative verification methods. This violated the facility's own policy requiring photo identification or staff verification before any medication administration.
The second error occurred with the same resident and nurse during MiraLAX administration. The medication requires immediate consumption after mixing with 4-6 ounces of fluid for proper effectiveness. However, the resident consumed only half the dose, leaving the remainder on the bedside table where it settled and became ineffective. The nurse failed to ensure complete consumption or remove the leftover medication, creating both therapeutic failure and potential contamination risks.
Improper Nasal Medication Technique
The third documented error involved incorrect administration of Flonase nasal spray to Resident 36. Licensed Vocational Nurse 1 failed to follow established protocols, which require patients to blow their nose beforehand and close one nostril while inhaling the medication into the other.
Instead, the resident inhaled the medication with both nostrils open and without proper breathing technique. This improper administration significantly reduces medication effectiveness and can lead to inadequate symptom control for conditions requiring nasal corticosteroids.
Nasal corticosteroids like Flonase require precise administration technique to reach target tissues in the nasal cavity. When administered incorrectly, the medication may not adequately reduce inflammation or control allergic symptoms, potentially leading to respiratory complications or reduced quality of life.
Quality Committee Oversight Failures
Perhaps most concerning was the discovery that the facility's Quality Committee had conducted only one meeting within the past year. During interviews on June 11, 2024, committee members including the Director of Staff Development, Assistant Director of Nursing, Director of Nursing, and Administrator could not recall specific discussions about medication errors during their single meeting.
The committee lacked any ongoing performance improvement project specifically targeting medication errors with measurable improvement outcomes. This represents a fundamental failure in the systematic approach required to identify, analyze, and prevent medication errors in long-term care settings.
Quality committees serve as the primary mechanism for identifying trends, implementing corrective actions, and monitoring improvement in nursing home operations. The absence of regular meetings and focused medication safety initiatives indicates inadequate oversight of patient safety protocols.
Infection Control Protocol Violations
Beyond medication errors, inspectors identified multiple infection control violations affecting residents on transmission-based precautions. Resident 32, who required contact isolation due to MRSA and Klebsiella infections, had no personal protective equipment available outside the room during multiple observation periods.
Licensed staff acknowledged the violations, with one nurse stating "I have no idea" when asked about the missing PPE cart location. This failure creates direct transmission risks for antibiotic-resistant bacteria between residents and healthcare workers.
For Resident 34, who required enhanced barrier precautions due to an indwelling urinary catheter, staff failed to use proper protective equipment during high-contact care activities. A licensed vocational nurse was observed handling the resident's urinary collection bag without gloves, gown, or mask, violating both facility policy and CDC guidelines.
Inadequate Activity and Dining Facilities
The facility also failed to provide adequate space for group activities and communal dining for its 43 residents. All activities occurred in hallways due to the absence of designated activity rooms, creating noise disturbances for residents in nearby rooms.
Resident 32 reported closing his door during hallway activities due to excessive noise, particularly during weekly karaoke sessions conducted directly outside his room. Another resident expressed preference for a proper dining room, stating "It would be nice to have a room than the hallway."
Industry Standards and Required Protocols
Medication error rates above 5% indicate systemic failures in nursing home medication management systems. Professional standards require multiple verification steps including patient identification, medication verification, proper administration technique, and documentation of complete dose consumption.
Infection control protocols for resistant organisms require strict adherence to contact precautions, including readily available PPE and proper use during all patient contact. The CDC specifically recommends enhanced barrier precautions for residents with indwelling devices regardless of known infection status.
Federal nursing home regulations require adequate space for activities and dining to promote resident well-being and social interaction. Conducting activities in hallways fails to provide the therapeutic environment necessary for resident engagement and recovery.
The documented violations at San Bruno Skilled Nursing represent multiple system failures requiring immediate corrective action to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Bruno Skilled Nursing from 2024-06-14 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.