LEMON GROVE, CA - Federal inspectors documented serious medication safety violations at Lemon Grove Care and Rehabilitation Center after observing a licensed nurse attempt to administer medication that had been thrown in the trash and leave prescription drugs unattended at a resident's bedside.
Contaminated Medication Administration Attempt
During an August 14, 2024 inspection, surveyors observed a licensed nurse (LN 10) administering medications to a resident with complex medical needs including stroke-related paralysis, dementia, and a feeding tube. The resident required seven different medications to be crushed and administered through the gastrostomy tube.
The nurse placed crushed medications into unlabeled cups, but when cold water was added, the powdered tablets did not fully dissolve and stuck to the sides and bottom of the containers. After administering what he believed were complete doses, the nurse threw away one cup containing a substantial amount of undissolved white powder.
Upon realizing medication remained in the discarded cup, the nurse retrieved it from the trash can where it sat on top of used personal protective equipment. He then prepared to readminister this contaminated medication to the resident before being stopped by the surveyor.
"I would not want to be given a medication that had been in the trash can if I were the resident," the nurse acknowledged when questioned about the infection control concerns.
Medication Identification Problems
The situation became more complex when the nurse initially identified the discarded medication as Amlodipine, a blood pressure medication, but later determined it was actually Vitamin D. This confusion arose because multiple medications had been crushed into similar white powders and placed in unlabeled cups.
The nurse explained he arranged the medication cups in a specific order to identify them, but this system failed when he could not accurately determine which medication had been discarded. When he prepared fresh Amlodipine and compared it to the discarded substance, he realized they looked different and concluded the wasted medication was Vitamin D instead.
This identification error demonstrates the risks of using unlabeled containers for crushed medications, particularly when multiple drugs have similar appearances after processing.
Medication Left Unattended Creates Safety Risk
Compounding the medication errors, the nurse left a cup containing dissolved Amlodipine unattended at the resident's bedside while he returned to the medication cart to obtain replacement Vitamin D. The privacy curtain was drawn, preventing the nurse from monitoring the medication.
When questioned about this practice, the nurse acknowledged it was inappropriate, noting that other residents in the room had cognitive impairments and one was able to get out of bed independently. This created a risk that confused residents might access medication not intended for them.
Leaving prescription medications unattended violates basic medication safety protocols designed to prevent accidental ingestion, medication theft, or confusion about which resident should receive specific drugs.
Blood Pressure Medication Given Without Safety Check
The inspection revealed the nurse administered Amlodipine without verifying the resident's current vital signs, despite physician orders requiring the medication be held if blood pressure dropped below 110 systolic or heart rate fell below 60 beats per minute.
The resident's vital signs were not entered into the electronic medical record until 9:13 AM, but the nurse had already begun medication administration before this time. The recorded blood pressure of 154/87 and heart rate of 98 would have been safe for Amlodipine administration, but the nurse could not have known this when he prepared and gave the medication.
Blood pressure medications require careful monitoring because giving them when blood pressure is already low can cause dangerous drops that may lead to falls, dizziness, or loss of consciousness. The hold parameters exist specifically to prevent these complications.
Unlocked Medication Cart Violation
During the observation, the nurse left his medication cart unlocked and unattended when he walked away to find disinfecting wipes. The cart remained unsecured for approximately two minutes in a hallway where residents and visitors could access it.
Medication carts must remain locked when not directly supervised to prevent unauthorized access to controlled substances and prescription medications. This security measure protects both residents and staff from potential medication theft, accidental ingestion, or medication errors caused by tampering.
Documentation and Dosing Errors
Inspectors identified additional medication administration problems including:
- Administering 25 ml of Lactulose instead of the prescribed 30 ml dose - Documenting administration of Lactobacillus that was never given to the resident - Failing to properly dissolve crushed medications before administration
The nurse acknowledged these errors during follow-up interviews, admitting he had charted medications incorrectly and failed to provide the full prescribed dose of Lactulose.
Lack of Specialized Training Revealed
When questioned about his competency with feeding tube medication administration, the nurse stated he could not recall receiving specific training or evaluation for this specialized skill. However, facility records showed he had been checked off on feeding tube medication competency in March 2024.
The Director of Staff Development confirmed that the observed medication administration was not performed competently and violated multiple safety protocols. She noted that when medication identification becomes uncertain due to unlabeled containers, the appropriate response is to stop the process and contact the physician rather than attempt to guess which medication was involved.
Facility Policy Violations
The violations contradicted several facility policies including requirements to: - Keep medication carts locked when unattended - Verify vital signs before administering medications with hold parameters - Accurately prepare and administer medications as prescribed - Dilute crushed medications with water to ensure complete dissolution
Quality Assurance Concerns
The inspection found the facility's medication error rate reached 8.33 percent, exceeding the federal standard requiring facilities maintain error rates below 5 percent. Three medication errors were documented during observation of just 36 medication administration opportunities involving two residents.
This elevated error rate indicates systemic problems with medication safety practices that extend beyond the specific violations observed during the inspection.
The facility must implement corrective measures to address staff competency, medication security, and administration protocols to ensure resident safety and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lemon Grove Care and Rehabilitation Center from 2024-08-15 including all violations, facility responses, and corrective action plans.
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