MISSION HILLS, CA - State inspectors documented multiple violations at Ararat Nursing Facility during an August 2024 survey, finding staff failed to conduct required medication safety assessments and ensure call lights remained within residents' reach, potentially compromising patient safety and autonomy.
Medication Self-Administration Rights Denied
Inspectors identified serious gaps in the facility's medication management protocols, particularly regarding residents' rights to self-administer medications when clinically appropriate. Two residents were found managing their own medications without proper assessments or physician orders, creating safety risks and violating federal regulations.
Resident 177, who was prescribed sodium chloride tablets for electrolyte imbalances, was discovered keeping medication in a bedside cup and taking it at her discretion. During the inspection, surveyors found two white tablets in a clear plastic cup on her bedside table. The resident explained that "the nurse gave her the tablets in the morning and she will take the tablets after eating lunch."
However, facility records revealed no medication self-administration assessment had been conducted for this resident, despite her cognitive capacity to make informed decisions. Licensed Vocational Nurse 1 acknowledged during interviews that "it is important to perform a medication self-administration assessment for resident safety, to accommodate the resident's needs, and respect the resident's rights."
Medical Implications of Assessment Failures
Medication self-administration assessments serve critical safety functions in nursing facilities. These evaluations determine whether residents possess the cognitive ability, manual dexterity, and understanding necessary to safely manage their medications. Without proper assessment, facilities cannot ensure residents understand dosing schedules, drug interactions, or potential side effects.
For residents with conditions like hyponatremia (low sodium levels) requiring electrolyte supplementation, timing and dosing precision becomes particularly important. Improper self-administration could lead to electrolyte imbalances, affecting cardiac function, neurological status, and overall health stability.
The assessment process also establishes necessary safeguards, including proper medication storage, staff monitoring protocols, and intervention procedures when residents experience cognitive changes or medication complications.
Unauthorized Supplement Use Raises Concerns
A second case involved Resident 227, who was observed taking Areds 2 supplements from a personal bottle despite having no physician's order for the medication. The resident, described by staff as alert and oriented with research background, had expressed desire during interdisciplinary team meetings to keep vitamins and supplements at bedside.
The facility's Minimum Data Set Coordinator confirmed during interviews that "there was a desire from Resident 227 to keep supplements and vitamins at the bedside... but they failed to assess the resident for self-administration of medications." Staff acknowledged the resident's cognitive capacity but failed to follow proper protocols.
Industry Standards for Medication Management
Federal regulations require nursing facilities to honor residents' rights to self-administer medications when determined safe by the interdisciplinary team. This process involves comprehensive assessment during admission, quarterly reassessments, and development of individualized care plans addressing medication storage, education, monitoring, and compliance management.
The assessment must evaluate multiple factors including cognitive function, manual dexterity, vision, understanding of medication purposes, ability to follow dosing schedules, and recognition of adverse effects. When residents demonstrate competency, physicians must provide specific orders authorizing self-administration of designated medications.
Proper implementation includes secure medication storage at bedside, staff education about monitoring requirements, and clear protocols for addressing non-compliance or emergent situations requiring intervention.
Call Light Access Compromised Patient Safety
Inspectors documented two residents unable to access their call lights, creating potential emergency response delays. Resident 159, who had a documented fall risk and required assistance with daily activities, was found lying in bed with his call light on the floor beyond his reach.
When surveyors observed the situation, the resident "stated he was unable to reach for his call light" and "attempted to get his call light from the floor but was unsuccessful." His care plan specifically required keeping the call light within easy reach as a fall prevention intervention.
Resident 14, who had dementia and required substantial assistance with mobility, was observed sitting in a wheelchair with the call light resting on the bed out of reach. When questioned, one nursing assistant incorrectly stated "the call light did not need to be within reach of the resident," demonstrating staff confusion about safety protocols.
Medical Risks of Inadequate Call Light Access
Call light accessibility represents a fundamental safety requirement in healthcare settings. Residents with mobility limitations, cognitive impairments, or fall risk factors depend on immediate access to summon assistance for toileting needs, pain management, position changes, or emergency situations.
When call lights remain out of reach, residents may attempt unsafe transfers or ambulation independently, significantly increasing fall risk. Falls in nursing facility residents can result in fractures, head injuries, functional decline, and increased mortality risk. For residents with dementia, inability to summon help may cause increased agitation, behavioral symptoms, or attempts at unsafe self-rescue.
Research demonstrates that prompt response to resident needs through accessible call systems reduces falls, improves satisfaction, and supports dignity through timely assistance with personal care needs.
Additional Issues Identified
The inspection revealed other concerning practices beyond the major violations. Staff demonstrated inconsistent understanding of medication management protocols, with some nursing personnel allowing unauthorized bedside medication storage while others acknowledged proper assessment requirements.
Documentation gaps appeared throughout resident records, suggesting systemic issues with care planning and monitoring processes. The facility's own policies clearly outlined appropriate procedures, but implementation appeared inconsistent across departments.
Communication breakdowns between nursing staff, physicians, and interdisciplinary team members contributed to delayed assessments and inadequate monitoring of resident condition changes.
These violations highlight the need for comprehensive staff education, improved communication systems, and enhanced monitoring of compliance with federal regulations governing resident rights and safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-08-09 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.