The violations put residents at risk for falls, fainting, and other complications from excessively low blood pressure and heart rates. In one case, nurses administered medication to a resident whose blood pressure had plummeted to 98/74 — well below the safety threshold established by doctors.
Resident #26, who suffered from multiple heart conditions including cardiomyopathy and atrial fibrillation, received the blood pressure drug Diltiazem despite physician orders to hold the medication when systolic pressure fell below 130. Records show nurses gave the drug on dozens of occasions when the resident's blood pressure was too low.
On June 8, the resident's blood pressure measured 115/55 at 9:00 AM, yet nurses administered the medication anyway. The same pattern repeated throughout May and June, with nurses ignoring the hold parameters on at least 40 separate occasions.
The medication errors weren't isolated incidents. Resident #53, prescribed Amlodipine for hypertension, faced similar risks when nurses disregarded orders to withhold the drug if blood pressure dropped below 110 or heart rate fell below 60 beats per minute.
On April 7, nurses gave the resident Amlodipine despite a blood pressure reading of 98/74 — dangerously low by any medical standard. Throughout the spring, they continued administering the medication when the resident's heart rate dropped to 54, 55, 56, and 58 beats per minute, all below the safety threshold.
The facility's Director of Nursing acknowledged the violations when confronted with medication records during the inspection. She told investigators she had conducted staff training on April 29 after the consultant pharmacist raised concerns about a different resident, but the unsafe practices continued well into June.
"I did in-service after pharmacist mentioned it on another resident," she stated, referring to the training session. Yet records show nurses continued giving medications outside safe parameters for nearly two months after the education session.
When inspectors interviewed Staff G, a licensed practical nurse, about the medication errors, she appeared confused about the safety protocols. Asked why she gave blood pressure medication to Resident #26 when the systolic reading was below 130, "she did not have an answer and why she gave it."
The facility's consultant pharmacist, responsible for reviewing all medications and safety parameters, told inspectors during a phone interview that he hadn't identified concerns with the problematic medications in the past six months. He claimed to review "all medications and parameters" but said he would only make recommendations if he had concerns — despite the clear pattern of unsafe administration.
A unit manager acknowledged that nurses "did not hold the medication as per physician order" when shown the medication records and physician orders side by side.
The inspection also revealed problems with psychotropic medication management. Resident #22, admitted to the facility under hospice care, received a prescription for Lorazepam — an anti-anxiety medication — without any specified duration for use, violating federal requirements that such medications be limited to 14 days unless extended with documented rationale.
The Lorazepam order, initiated February 29, allowed the medication to be given every four hours as needed for anxiety, but lacked any end date or duration. The consultant pharmacist acknowledged during his interview that medications should have "a specific duration of time" and require re-evaluation for continued use beyond 14 days.
Medical record accuracy posed another concern. Physician progress notes for Resident #37 contained contradictory information about psychotropic medication doses. While current orders prescribed clonazepam 0.5 mg daily, Seroquel 100 mg in the morning and 50 mg at bedtime, and trazodone 25 mg at bedtime, physician notes documented different doses entirely.
A June 10 progress note listed clonazepam at 1 mg, Seroquel at 50 mg and 25 mg, and trazodone at 50 mg — none matching the actual prescribed doses. An earlier note from February also contradicted the trazodone order.
The facility's infection control procedures also failed inspection standards. When Resident #61 tested positive for Clostridium difficile, a highly contagious intestinal infection, staff waited two days to write isolation orders despite reviewing the positive laboratory results immediately.
The stool sample results, confirming C. difficile infection, were reviewed by facility staff on June 15. However, contact precaution orders weren't written until June 17, potentially exposing other residents and staff to the dangerous bacteria during the delay.
The facility's Infection Preventionist explained she conducts isolation audits only on Mondays and discovered the missing order during her routine review. "She stated she does not ever back date anything, so the order was written after the diagnosis and precautions were instituted," inspectors noted.
The violations at Lakeside Health Center reflect systemic failures in medication safety and clinical oversight. Despite having policies requiring proper medication administration and timely isolation procedures, staff repeatedly ignored physician orders designed to protect vulnerable residents from preventable harm.
The facility's 2501 N Australian Avenue location houses residents with complex medical conditions requiring careful medication management and infection control. When those basic safety measures fail, residents face increased risks of falls, cardiac events, and infectious disease spread — consequences that can prove devastating for an already fragile population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeside Health Center from 2024-06-20 including all violations, facility responses, and corrective action plans.