LONG BEACH, CA - Federal inspectors documented systematic medication errors at Windsor Convalescent Center of North Long Beach, where nursing staff repeatedly applied prescription pain cream to the wrong body part for months.
Medication Applied to Wrong Location
During a June 2024 inspection, investigators found that nursing staff had been applying lidocaine cream to a resident's left knee instead of the right shoulder as specified in physician orders. The error occurred consistently from March through June 2024, with documentation showing incorrect application on multiple dates.
The resident, identified as Resident 102, was admitted in January 2024 with diagnoses including pain in the right elbow, psychosis, and depression. Physician orders dated January 9, 2024, specifically instructed staff to apply lidocaine external cream to the right shoulder topically once daily for shoulder pain.
However, medication administration records revealed a pattern of incorrect application. In March 2024, staff applied the cream to the left knee on five separate occasions. This pattern continued through April with five more incorrect applications, and throughout May the cream was applied daily to the wrong location from May 1-25.
Resident's Ongoing Pain Complications
Medical evaluations showed Resident 102 faced significant mobility challenges related to the left knee. A physical therapy evaluation from January indicated the resident's left hip was fixed at 90 degrees of flexion and the knee at 140 degrees of flexion. The resident had undergone washout surgery for a septic knee infection and developed a left leg contracture.
Pain assessments documented escalating discomfort. In February, the resident reported constant left knee pain at level 7 out of 10 on the standard pain scale. By late February, pain intensity had increased to 8 out of 10, described as dull and aching.
Physical therapy records from March showed the resident could tolerate wearing a knee extension splint for four hours. Therapy staff provided training to restorative nursing aides for proper range of motion exercises and splint application.
Staff Recognition of Error
During inspector observations in June 2024, staff acknowledged awareness of the medication discrepancy. The Director of Nursing confirmed during interviews that physician orders specified lidocaine cream for the right shoulder, while nursing staff had been applying it to the left knee to address the resident's knee pain complaints.
Observational records showed the resident expressing frustration with treatment effectiveness. During a morning session, the resident told staff that "the left knee has not improved even with exercises." Staff noted the resident sometimes cried due to left knee pain intensity.
Medication Administration Standards
Federal regulations require nursing facilities to administer medications exactly as prescribed by physicians. The facility's own policies stated that medications must be given "in accordance with written orders of the attending physician."
Lidocaine cream provides localized pain relief through numbing effects on nerve endings in the applied area. When applied to the wrong location, the medication cannot address the prescribed condition while potentially masking symptoms at the incorrect site.
Clinical Implications
The medication error represents multiple clinical concerns. First, the resident's prescribed right shoulder pain remained untreated for months. Second, applying topical anesthetics to areas with existing infections or surgical sites requires careful medical oversight to prevent complications.
For residents with contractures and joint limitations, proper pain management becomes essential for maintaining function and preventing further deterioration. When pain medications are misdirected, residents may experience unnecessary discomfort that could affect their participation in therapy and daily activities.
Communication Failures
Medical records indicated Resident 102 maintained clear speech and intact cognitive function, meaning effective communication about treatment was possible. Despite the resident's ability to communicate and express concerns about persistent knee pain, the medication error continued for months.
The systematic nature of the error suggests gaps in medication verification procedures. Standard protocols typically require nurses to verify the "five rights" of medication administration: right patient, right drug, right dose, right route, and right site.
Facility Response and Oversight
The inspection classified this violation under F755 with minimal harm or potential for actual harm, affecting some residents. While not categorized as immediate jeopardy, the sustained nature of the error over multiple months indicates systemic issues in medication management oversight.
Federal regulations require nursing facilities to maintain systems that prevent medication errors through proper training, supervision, and verification procedures. When errors are identified, facilities must implement corrective measures to prevent recurrence.
The violation demonstrates the importance of regular medication administration audits and staff retraining on proper procedure verification. For residents with complex medical conditions requiring multiple interventions, coordinated care planning becomes essential to ensure all prescribed treatments are delivered correctly.
This case highlights how seemingly minor procedural errors can compound over time, affecting resident comfort and treatment outcomes when basic medication administration protocols are not consistently followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Convalescent Center of North Long Beach from 2024-06-28 including all violations, facility responses, and corrective action plans.
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