PASADENA, CA - State inspectors at Golden Rose Care Center documented significant medication administration failures affecting multiple residents, including critical timing violations and missed doses of life-sustaining medications during a July 11, 2024 complaint investigation.
Critical Timing Violations Impact Cardiovascular Patients
The inspection revealed that Licensed Vocational Nurse 3 failed to administer 12 scheduled medications to Resident 208 within the facility's required one-hour window on July 10, 2024. The resident, who has a complex medical history including stroke with left-side paralysis, high blood pressure, and heart conditions, was prescribed multiple time-sensitive medications to manage these serious conditions.
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM. This delay exceeded the facility's policy allowing medications to be given one hour before or after the scheduled time. Two critical heart medications - Metoprolol Tartrate for blood pressure control and Ranolazine for chest pain prevention - were specifically ordered to be taken with breakfast at 7:30 AM but were not given until 10:27 AM, well after the morning meal.
The resident's medication regimen included 12 different drugs managing conditions ranging from seizure control to heart failure. These included Digoxin for heart efficiency, Eliquis to prevent dangerous blood clots, Lasix for fluid retention, and two anti-seizure medications - Lacosamide and Levetiracetam.
Medical Consequences of Delayed Administration
Medication timing violations create serious health risks for residents with complex medical conditions. When cardiovascular medications are not taken as prescribed, the therapeutic blood levels necessary for optimal treatment cannot be maintained. This is particularly critical for residents like Resident 208, who relies on multiple medications working in coordination to manage stroke recovery, heart failure, and high blood pressure.
Blood pressure medications like Metoprolol work by maintaining steady levels in the bloodstream. Delays in administration can cause fluctuations that may lead to dangerous spikes in blood pressure or inadequate cardiovascular protection. Similarly, anti-seizure medications require consistent timing to prevent breakthrough seizures, which can be life-threatening for residents with epilepsy.
The facility's Registered Nurse Supervisor acknowledged during the inspection that "medications that were given late might be close to next scheduled dose and might lead to overdosing." This creates additional risk when the next dose is due, potentially causing dangerous medication interactions or toxicity.
Thyroid Medication Completely Missed
The inspection also revealed that Resident 3, who has quadriplegia, epilepsy, and hypothyroidism, missed two complete doses of levothyroxine sodium on January 12 and January 16, 2024. Levothyroxine is the primary treatment for hypothyroidism, a condition where the thyroid gland cannot produce adequate hormones essential for metabolism and overall bodily functions.
This resident requires levothyroxine 175 micrograms daily at 6:00 AM to maintain proper thyroid hormone levels. The medication was prescribed to start December 24, 2023, but facility records showed the doses were simply not administered on the documented dates.
Thyroid hormone replacement therapy requires consistent daily dosing to maintain therapeutic levels. Missing doses can lead to symptoms of hypothyroidism returning, including fatigue, depression, weight gain, and cognitive impairment. For a resident with existing severe disabilities, these additional complications can significantly impact quality of life and overall health status.
Industry Standards for Medication Management
Nursing home medication administration follows strict federal and state guidelines designed to protect vulnerable residents. The standard "five rights" of medication administration - right patient, right drug, right dose, right route, and right time - form the foundation of safe pharmaceutical care in long-term care settings.
Timing requirements exist because many medications have specific absorption characteristics, interaction patterns with food, or narrow therapeutic windows. Heart medications often require precise timing to maintain cardiovascular stability, while thyroid medications must be taken consistently to replace the body's natural hormone production.
The facility's own policy, revised June 1, 2017, clearly states that "medications may be administered one hour before or after the scheduled medication administration time." This policy aligns with industry standards recognizing that some flexibility is necessary in institutional settings while maintaining therapeutic effectiveness.
Administrative Oversight Failures
The violations highlight broader systemic issues within the facility's medication management program. Licensed nurses are responsible for ensuring residents receive medications as prescribed, documenting administration times accurately, and following facility policies designed to prevent errors.
The failure to document actual administration times in the medication administration record compounds the safety risk by making it difficult to track medication effectiveness or identify patterns of non-compliance. Accurate documentation is essential for physicians to assess treatment effectiveness and adjust prescriptions as needed.
During the inspection, the Director of Nursing acknowledged the serious nature of these violations, stating that "if medications were not given timely, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition." The administrator further noted that delayed administration of Resident 208's heart medications "can cause complications such as death."
Additional Issues Identified
The inspection also documented other areas of concern related to the facility's pharmaceutical services program. The investigation revealed inconsistencies in nursing staff understanding of medication policies and procedures, particularly regarding the importance of meal timing for specific medications.
Staff interviews indicated confusion about the rationale behind specific timing requirements, suggesting inadequate training on the clinical importance of medication schedules. This knowledge gap represents a significant risk factor for future medication errors and resident safety concerns.
The facility's medication administration records showed additional documentation deficiencies beyond the specific violations cited, indicating potential systemic issues with pharmaceutical services oversight and quality assurance processes.
The violations occurred during a complaint-based inspection, suggesting that concerns about medication management may have prompted the state's investigation. Such inspections typically focus on specific areas of resident care where problems have been reported or observed.
Golden Rose Care Center serves residents with complex medical needs requiring sophisticated medication management protocols. The facility's location at 1899 N Raymond Ave in Pasadena places it within a competitive long-term care market where families expect high-quality pharmaceutical services as part of comprehensive resident care.
State oversight of nursing home medication practices continues to intensify as regulators recognize the critical importance of proper pharmaceutical care for vulnerable elderly residents. These violations demonstrate the ongoing challenges facilities face in maintaining consistent, safe medication administration practices across all shifts and staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Rose Care Center from 2024-07-11 including all violations, facility responses, and corrective action plans.
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