BURBANK, CA - A July 2024 inspection at Alameda Care Center revealed significant medication errors and food safety violations that put vulnerable residents at risk, according to findings from state health inspectors.
Critical Medication Management Failures Endanger Diabetic Residents
The most serious violations involved multiple medication errors that could have life-threatening consequences for diabetic residents. Inspectors found that nursing staff repeatedly failed to follow physician-ordered protocols for insulin administration and blood sugar monitoring.
In one case, a resident with Type 2 diabetes and cognitive impairment received insulin injections at the same body site repeatedly, despite physician orders to "rotate site." Medication Administration Records showed staff administered insulin to the same injection areas for consecutive days, including giving injections to the left lower quadrant on multiple consecutive dates in May, June, and July 2024.
The facility's Registered Nurse acknowledged that "there were multiple instances where the injection sites of the insulin were not rotated" and stated that "the failure to follow the physician's order to rotate the insulin administration site is considered a medication error."
Proper insulin injection site rotation is critical for preventing lipodystrophy - abnormal fat distribution that can cause hard lumps under the skin. When injection sites aren't rotated, the skin can develop hardened areas that prevent proper insulin absorption, making blood sugar control unpredictable and potentially dangerous.
Dangerous Blood Sugar Protocol Violations
Even more concerning were violations involving blood sugar parameters. Inspectors documented cases where nursing staff administered insulin to residents despite blood sugar readings below the safety threshold specified in physician orders.
One resident's medication orders clearly stated to "hold for BS less than 90," yet staff administered insulin when the resident's blood sugar was 89 and 80 mg/dL respectively. A Licensed Vocational Nurse admitted during the inspection that "she gave the resident insulin with BS below 90, when it should have been held to prevent the BS from going down even lower."
The facility's Director of Nursing confirmed that "the parameters the physician ordered must always be followed to prevent hypoglycemia" and stated that "not following the physician ordered parameters during administration of insulin constitutes a medication error."
These protocol violations are particularly dangerous because they can trigger severe hypoglycemia - a condition where blood sugar drops to life-threatening levels. Symptoms can include confusion, seizures, unconsciousness, and potentially death if not treated immediately.
Delayed Antibiotic Treatment During Disease Outbreak
Perhaps most alarming was a case involving delayed antibiotic treatment during an active Group A Streptococcus outbreak at the facility. Inspectors found that a resident with infected wounds didn't receive prescribed antibiotics for over seven hours after the medication was ordered.
The facility's Treatment Nurse stated that "antibiotics should be given immediately or within two hours of an order" and acknowledged that "when antibiotics are delayed a wound can worsen." The nurse admitted it was 1:45 p.m. and antibiotics still hadn't been administered, despite being ordered that morning.
During an active infectious disease outbreak, rapid treatment is essential to prevent complications and limit spread to other residents. The facility's Infection Preventionist emphasized that "when the wound care consultant gave a verbal order for antibiotics, the antibiotics should have been started within four hours because the resident has an infection, they want to stop the infection from worsening, and to prevent the outbreak from spreading to other residents."
The facility's Director of Nursing called this delay "a medication error" and stated the antibiotic "should have been given to the resident as soon as possible and not the following day."
Food Safety and Dietary Violations
Beyond medication errors, inspectors identified numerous food safety violations that could expose residents to foodborne illness. Problems included damaged refrigerator shelving with chipped and cracked surfaces, dirty freezer shelves with dried liquid buildup, and contaminated food preparation equipment.
Kitchen equipment showed signs of poor maintenance with mixers having "dirt and food buildup" and food carts containing "dried up milk spill and tape residues." Staff acknowledged these conditions "could attract germs" and that "residents could get sick with diarrhea, vomiting, upset stomach and food poisoning."
The dietary department also failed to properly follow special diet requirements. One resident on a vegan and lactose-free diet received grilled cheese sandwich and bread stuffing containing dairy products and animal-derived ingredients - directly contradicting their prescribed dietary restrictions.
Additional Issues Identified
Inspectors found several other concerning practices that compromised resident safety and quality of care:
- Puree diet safety violations: Staff added parsley flakes as garnish to pureed foods, creating choking hazards for residents with swallowing difficulties - Food storage violations: Dented cans were stored with undamaged products, and resident food from home lacked proper labeling and dating - Sanitation failures: Multiple areas of the kitchen showed dust, debris, and contamination that could harbor harmful bacteria - Waste management problems: Garbage areas had accumulated trash and liquid drippings that could attract pests and spread infection - Hospice coordination deficiencies: The facility lacked clearly designated staff responsible for coordinating hospice services
These violations collectively demonstrate systemic problems with medication management, infection control, food safety protocols, and overall resident care coordination. The combination of medication errors during a disease outbreak, coupled with food safety violations, created conditions where medically compromised residents faced multiple health risks simultaneously.
The inspection findings highlight the critical importance of strict adherence to medication protocols, especially for diabetic residents whose health depends on precise insulin management and blood sugar monitoring. Proper staff training, clear policies, and consistent oversight are essential to prevent such violations from recurring and ensure resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alameda Care Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
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