NORTH HOLLYWOOD, CA - Federal inspectors documented significant medication management failures at Sherman Village HCC during a September 2024 inspection, finding the facility administered duplicate medications and failed to properly monitor a diabetic hospice patient's blood sugar levels for months.
Duplicate Medications Continued After Symptoms Resolved
The most concerning violation involved a hospice patient who received two different medications for the same condition long after symptoms had resolved. According to the inspection report, the resident was prescribed both Claritin and Vistaril for itching, with both medications administered twice daily since May 25, 2024.
Facility records showed the patient's itching symptoms had resolved by June 2024, yet both medications continued to be administered through September. Documentation indicated the resident "did not complain of itching" on multiple dates, with staff notes stating "No itchiness present or noted" and "resolved" by early August.
The dual administration presented unnecessary medication exposure risks. Both Claritin and Vistaril can cause drowsiness, confusion, and other side effects in elderly patients. When administered together without medical justification, these effects can compound.
During the inspection, a hospice registered nurse acknowledged the oversight, stating that "once symptoms resolve then medications for those symptoms were no longer needed and would be discontinued after a short time." The nurse admitted to visiting the patient weekly and reviewing medications but failing to discontinue the unnecessary prescriptions.
Blood Sugar Monitoring Failures in Diabetic Patient
Inspectors also found the facility failed to obtain required blood sugar monitoring tests for the same hospice patient, who had Type 2 diabetes and was receiving insulin injections. The consultant pharmacist had specifically recommended on July 19, 2024, that the facility obtain an HbA1c test to monitor the patient's blood sugar control, noting a concerning glucose reading of 190.
HbA1c tests measure average blood sugar levels over 2-3 months and are critical for diabetes management. Without this monitoring, medical professionals cannot determine if insulin therapy is effective or if dosage adjustments are needed.
The attending physician disagreed with the recommendation, marking "Per MD no labs, Hospice patient end of life comfort measures" on the consultant's note. However, the Director of Nursing confirmed during the inspection that no physician order existed to stop laboratory services, and that proper blood sugar monitoring was essential even for hospice patients.
Antidepressant Medication Concerns
The inspection revealed additional concerns regarding the patient's antidepressant medication. The resident had been prescribed Escitalopram (Lexapro) since March 2023 for depression, but facility records showed no documented depression symptoms between January and June 2024.
Federal guidelines require nursing homes to attempt gradual dose reductions of psychotropic medications at least twice in the first year, then annually thereafter, unless clinically contraindicated. The consultant pharmacist recommended considering a dose reduction, but the physician again disagreed without providing adequate documentation of why the medication should continue.
Missing Clinical Justifications
Proper medication management requires documented clinical rationale for continuing treatments. The facility's own policies required staff to ensure medications treat existing conditions and address significant risks, with appropriate monitoring and assessment.
The Director of Nursing acknowledged multiple failures during the inspection, stating the facility should have either attempted dose reductions or documented specific contraindications preventing such attempts. The DON noted these oversights placed the patient "at risk of continuing unnecessary medications including psychotropic medications that could result in adverse consequences and side effects."
Industry Standards and Best Practices
Long-term care facilities must maintain strict medication oversight, particularly for vulnerable populations like hospice patients. Standard protocols require:
- Regular review of all medications to ensure continued necessity - Discontinuation of treatments when symptoms resolve - Appropriate monitoring of chronic conditions like diabetes - Documentation of clinical rationale for continuing psychotropic medications - Coordination between facility staff and hospice providers
Medication errors in nursing homes can lead to serious complications, including drug interactions, unnecessary side effects, masking of new health issues, and increased risk of falls or cognitive impairment.
Facility Response and Corrective Actions
The Director of Nursing indicated the facility would review all hospice orders and improve coordination with hospice providers to ensure appropriate care plan implementation. The facility's policies already addressed many of the identified issues, but implementation appeared inadequate.
Sherman Village's medication therapy policy states that each resident's regimen should include "only those medications necessary to treat existing conditions and address significant risks." The hospice program policy emphasizes coordinating care to "maintain the resident's highest practicable physical, mental and psychosocial well-being."
Regulatory Context
The violations fell under federal nursing home regulations requiring facilities to ensure drug regimens are free from unnecessary medications and that psychotropic drugs are properly managed. While classified as causing "minimal harm or potential for actual harm," these medication management failures represent systemic issues that could affect multiple residents.
The inspection findings highlight the importance of robust medication oversight systems, particularly for complex patients receiving both facility and hospice services. Proper coordination between healthcare providers and regular medication reviews are essential safeguards for resident safety and quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Village Hcc from 2024-09-06 including all violations, facility responses, and corrective action plans.
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