PETALUMA, CA - Federal inspectors documented a dangerous 24% medication error rate at North Bay Post Acute during a January 2025 inspection, uncovering serious safety violations that put residents at risk of injury and death.
Critical Medication Safety Failures
During observations on January 15, 2025, inspectors witnessed six medication errors out of 25 medication administrations across multiple shifts. The violations included potentially life-threatening incidents that could have resulted in serious harm to diabetic residents.
The most serious incident involved a registered nurse who nearly administered double the prescribed insulin dose to a diabetic resident. The nurse checked the resident's blood sugar level, which measured 205 mg/dL, but incorrectly documented it as 305 mg/dL in the medication record. Based on this error, she prepared to give 8 units of insulin instead of the correct 4 units.
The error was only caught when inspectors asked to see the glucometer history. The nurse realized her mistake, stating "Oh, my god! That would have been so bad."
The facility's Medical Director confirmed that administering too much insulin "is always life threatening," while the pharmacist noted that doubling the insulin dose could cause "significant damage" to the resident.
Pattern of Medication Administration Violations
Additional medication errors documented during the inspection included:
Potassium Administration Error: A nurse gave a resident with chronic kidney disease only 2 ounces of water with potassium medication, despite physician orders requiring 4 ounces to prevent gastrointestinal irritation.
Safety Instruction Failure: Staff failed to instruct a resident to remain upright for 10 minutes after taking potassium-phosphate medication, as required by manufacturer guidelines to prevent stomach irritation. The resident was observed lying flat in bed shortly after receiving the medication.
Dosage Errors: A nurse administered twice the prescribed dose of vitamin D to a resident, giving two tablets instead of one as ordered by the physician.
Improper Medication Preparation: Nursing staff mixed a laxative with insufficient water - approximately 2.5 ounces instead of the required 4-8 ounces according to manufacturer directions.
Timing Violations: Insulin was administered after meals despite physician orders specifying administration before meals, which affects blood sugar management effectiveness.
Mental Health Services Denied to Vulnerable Residents
The inspection revealed that the facility failed to provide mental health services to residents with documented psychiatric conditions. One resident with severe depression, anxiety, panic disorder, and post-traumatic stress disorder had not received any behavioral health services despite being admitted with these diagnoses.
The resident, who had thoughts of self-harm and was receiving medication for PTSD and psychosis, was recommended for psychology referral in July 2023 but never received services. During the inspection, she remained isolated in her room most days and told inspectors: "I've been dealing with so much mentally for [AGE] years, I'm sad mostly all day."
The resident specifically requested counseling services from social services staff, but the Social Services Director confirmed no mental health professional had evaluated or treated her. Even the facility Administrator expressed surprise, stating "I'm very surprised, she should have had help."
Inadequate Mental Health Screening Process
The facility also failed to properly screen residents for specialized mental health services through the required PASRR (Preadmission Screening and Resident Review) process. Despite being admitted with multiple psychiatric diagnoses and receiving psychotropic medications, the resident's initial screening incorrectly indicated no mental health conditions.
Federal regulations require facilities to ensure residents with mental health conditions receive appropriate specialized services. The facility's own policy states that residents "will receive behavioral health services," yet implementation was clearly lacking.
Additional Safety and Care Violations
Medication Storage and Security: Inspectors found unlocked medication carts left unattended, insulin pens without proper dating for expiration tracking, and a medication tablet on the floor under a resident's bed.
Missed Monthly Medication Reviews: The facility pharmacist failed to conduct required monthly medication reviews for residents, potentially missing drug interactions or unnecessary medications.
Delayed Dental Care: One resident did not receive routine dental services for 16 months, despite having multiple missing teeth and requesting dental visits.
Food Safety Issues: Kitchen equipment showed contamination with dust and grease buildup, and the facility lacked refrigeration for residents to store personal food items safely.
Understanding Medication Error Risks
Medication errors in nursing homes pose significant health risks, particularly for elderly residents with multiple chronic conditions. Insulin errors are especially dangerous because blood sugar levels that drop too low can cause confusion, seizures, coma, or death.
The 24% error rate documented at North Bay Post Acute far exceeds the 5% threshold considered acceptable under federal standards. This level of errors indicates systemic problems with medication administration training, supervision, and quality control measures.
Proper medication administration requires following the "five rights": right patient, right medication, right dose, right route, and right time. The violations at North Bay Post Acute touched on multiple aspects of this fundamental safety protocol.
Mental Health Care Standards
Federal nursing home regulations require facilities to provide mental health services to residents who need them. For residents with conditions like PTSD, depression, and anxiety disorders, appropriate treatment can significantly impact quality of life and overall health outcomes.
Mental health conditions in nursing home residents often go untreated, leading to social isolation, worsening depression, and potential safety risks. The failure to provide services despite clear documentation of need represents a serious gap in resident care.
Previous Inspection History
The facility has faced multiple citation cycles in recent years, suggesting ongoing challenges with regulatory compliance and quality improvement efforts. The current violations indicate that previous corrective action plans may not have effectively addressed systemic issues.
Facility Response Required
North Bay Post Acute must submit a plan of correction addressing each violation within specified timeframes. The plan must demonstrate how the facility will prevent future occurrences and ensure resident safety. State and federal oversight will continue until violations are resolved and sustained improvement is demonstrated.
The inspection findings highlight the critical importance of robust quality assurance programs in nursing homes, particularly around medication safety and mental health care provision. Families considering placement should inquire about facilities' error rates, staff training programs, and mental health service availability.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Bay Post Acute from 2025-01-17 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.