ANAHEIM, CA - Harbor Villa Care Center received multiple citations during a January 10, 2025 state inspection, with investigators documenting a medication error rate of 23.33% - more than four times the maximum allowable threshold of 5%.
Critical Medication Administration Failures Documented
The most serious violations centered on systematic medication administration errors affecting multiple residents. During observation periods, all three licensed nurses monitored made significant errors that could have compromised resident safety and treatment outcomes.
Failure to Administer Prescribed Medications: Licensed Vocational Nurse 3 was observed completely failing to administer three critical medications to Resident 745, including tamsulosin for enlarged prostate symptoms, duloxetine for depression, and quetiapine for manic disorder with auditory hallucinations. Despite not giving these medications, the nurse documented them as administered on the Medication Administration Record (MAR).
Improper Respiratory Medication Protocol: LVN 1 failed to follow required assessment protocols when administering budesonide, a steroid respiratory medication for a resident with COPD. The physician's orders specifically required monitoring blood pressure, apical pulse, and lung sounds before and after administration, but the nurse administered the medication without conducting these critical assessments.
Food Administration Requirements Ignored: LVN 2 administered Augmentin antibiotic and ferrous sulfate iron supplement without food, despite specific requirements to take these medications with meals. The antibiotic packaging included clear instructions to take with food to prevent stomach upset, while the physician's order for iron explicitly stated "take with food."
Medical Significance of Medication Errors
These violations represent serious departures from standard medical care protocols. When antidepressants and antipsychotic medications are suddenly discontinued, residents can experience withdrawal symptoms, mood destabilization, and potential psychiatric crisis. For Resident 745, missing doses of quetiapine could have led to increased hallucinations and behavioral disturbances.
Respiratory medications like budesonide require careful monitoring because they can affect heart rate and blood pressure. Without proper assessment, nurses cannot detect adverse reactions or determine if the medication is effectively treating the underlying COPD condition.
Taking iron supplements without food significantly increases the risk of gastrointestinal irritation, nausea, and poor absorption. Similarly, antibiotics taken on an empty stomach can cause stomach upset and may reduce the medication's effectiveness in treating infections.
Improper Consent Documentation for Psychiatric Medications
The facility also violated federal requirements for obtaining informed consent for psychoactive medications. For Resident 64, who was documented as not competent to make medical decisions, the facility incorrectly listed the resident's own name as the person providing consent for three psychiatric medications: mirtazapine, quetiapine, and valproic acid.
Documentation Error Acknowledged: When questioned by investigators, LVN 4 stated she obtained consent from the resident's family members but could not provide specifics. The Director of Nursing acknowledged the error, confirming that a family member's name should have been documented as the consent provider, not the incompetent resident's name.
This violation is particularly concerning because psychoactive medications carry significant risks and potential side effects. Federal regulations require that when residents cannot provide informed consent due to cognitive impairment, legally authorized representatives must be properly identified and their consent accurately documented.
Legal and Ethical Implications
Proper informed consent protects residents' rights and ensures families understand the benefits and risks of psychiatric medications. When documentation incorrectly suggests an incompetent resident provided their own consent, it creates legal vulnerabilities and suggests inadequate oversight of psychoactive drug administration.
Psychiatric medications like quetiapine and valproic acid can cause serious side effects including sedation, movement disorders, metabolic changes, and interactions with other medications. Family members serving as healthcare decision-makers need accurate information to make informed choices about their loved one's psychiatric treatment.
Systemic Issues in Medication Management
The inspection revealed that medication errors were not isolated incidents but reflected broader systemic problems. The 23.33% error rate indicates that nearly one in four medication administrations involved some form of error - a rate that far exceeds acceptable standards and suggests inadequate supervision, training, or quality assurance measures.
Supply Chain Management Problems: The facility also demonstrated poor medication inventory management. For Resident 745, the pharmacy consultant confirmed that tamsulosin, duloxetine, and quetiapine medications had run out of supply between January 2-3, 2025, yet the facility continued documenting these medications as administered through January 7.
The facility's own policies required reordering medications five days in advance to ensure adequate supply, but this protocol was not followed. When medications are unavailable, facilities must either obtain emergency supplies or document the omission and notify physicians for alternative treatment plans.
Additional Issues Identified
Beyond the major medication violations, the inspection documented several other concerning practices:
Incomplete Medication Preparation: During one observation, a nurse left medication residue in a medicine cup after crushing tablets, indicating incomplete dose administration that could result in under-dosing.
Missing Clinical Assessments: Required pre-administration assessments for cardiovascular and respiratory medications were consistently omitted, preventing early detection of adverse reactions or contraindications.
Documentation Inconsistencies: Multiple instances where medication administration records did not accurately reflect what was actually administered to residents.
These findings suggest the need for comprehensive staff retraining, enhanced supervision protocols, and improved quality assurance systems to ensure resident safety and regulatory compliance. The facility must address both the immediate medication errors and the underlying systems that allowed such widespread problems to occur.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbor Villa Care Center from 2025-01-10 including all violations, facility responses, and corrective action plans.
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