ORANGE, CA - A federal inspection at Healthbridge Children's Hospital's skilled nursing facility revealed multiple safety and care protocol failures affecting medically fragile pediatric residents dependent on ventilators, feeding tubes, and respiratory equipment.
Feeding Tube Safety Protocols Compromised
Federal inspectors documented critical lapses in tube feeding safety protocols for Resident 1, a patient requiring gastrostomy tube (GT) feeding along with tracheostomy and ventilator support. During multiple observations on February 19-20, 2025, the resident's bed position was measured at only 20 degrees elevation—significantly below the facility's own policy requiring 30-45 degrees during feeding.
This positioning failure presents serious medical risks. When patients receive nutrition through feeding tubes while lying too flat, gravity cannot assist in moving formula safely into the stomach. Instead, liquid nutrition can more easily reflux back up the esophagus and potentially enter the airway, causing aspiration pneumonia—a life-threatening infection that occurs when foreign material enters the lungs.
The risk escalates substantially for patients like Resident 1 who have both a tracheostomy (a surgically created opening in the windpipe) and require mechanical ventilation. The tracheostomy creates a direct pathway to the lungs, bypassing natural protective mechanisms that normally prevent aspiration. Proper head elevation becomes even more critical for these medically complex patients, as aspiration events can quickly progress to respiratory distress, ventilator-associated pneumonia, or respiratory failure.
Multiple staff members demonstrated awareness of the correct positioning requirement during interviews. Respiratory Therapist 1 confirmed that beds should be elevated to at least 30 degrees to reduce aspiration risk. Registered Nurse 2 acknowledged the error, initially stating she believed elevation should exceed 45 degrees. Licensed Vocational Nurse 1 and Certified Nursing Assistant 2 both verified the 30-degree standard, with the CNA noting she learned this requirement through facility training programs.
Despite this widespread knowledge among staff, the positioning violation persisted across two separate days of observation. When RN 2 entered the room during the second observation and confirmed the bed was elevated to only 20 degrees using an angle measurement tool, she immediately adjusted it to the correct height.
The inspection also identified a systematic problem with feeding formula labeling. Facility policy requires documentation of initials, date, and time when formula is hung and administered, with verification that labels match physician orders. However, staff confirmed no system existed for labeling when feeding formula was actually added to bags.
LVN 4 explained that night shift staff changed feeding and water flush bags every 24 hours, but only that change time appeared on labels—not when formula was added. This meant nursing staff had no way to verify formula freshness without accessing computer records. For Resident 1's prescribed Boost Kids Essentials with fiber given three times daily, this labeling gap created potential food safety concerns, as healthcare facilities must track how long formula remains at room temperature to prevent bacterial growth.
Respiratory Equipment Maintenance Failures
The facility's respiratory therapy program showed systematic failures in equipment maintenance and dating protocols, creating infection control risks for two residents with chronic respiratory conditions.
Resident 7, diagnosed with chronic respiratory failure and tracheostomy status, required continuous cool aerosol therapy—a treatment delivering medicated mist to help manage upper airway issues by loosening secretions. During the initial facility tour on February 6, 2025, inspectors observed the plastic bag containing aerosol equipment dated February 6. When respiratory therapist RT 3 was asked about the setup during a follow-up observation on February 20, the equipment still bore the same date—despite facility policy requiring weekly changes.
RT 3 acknowledged the equipment should have been replaced on February 13, confirming a seven-day lag in following the facility's infection control protocols. Respiratory equipment that remains in use beyond recommended timeframes becomes a breeding ground for bacteria and other pathogens. When contaminated equipment delivers moisture directly to airways—particularly in patients with compromised respiratory systems—it can introduce infections into already vulnerable lungs.
For pediatric patients with congenital heart malformations like Resident 7, respiratory infections carry heightened danger. The heart defects present at birth already stress the cardiovascular system; adding respiratory infections creates a dangerous dual burden that can rapidly deteriorate into medical crisis.
Resident 9 faced different but equally concerning equipment maintenance lapses. During observation on February 19, inspectors found the suction canister—which collects secretions like mucous and phlegm during airway suctioning—contained 60-70 milliliters of whitish secretions but lacked any date marking. LVN 5 verified during a concurrent interview that all suction canisters must be dated when installed and connected to suction machines.
This dating requirement serves critical purposes in infection prevention. Suction canisters collect biological material that provides ideal conditions for bacterial proliferation. Without date markings, staff cannot determine how long a canister has been in use or whether it requires changing per the facility's weekly replacement protocol. For Resident 9, who depends on a ventilator and lives with acute and chronic respiratory failure with hypoxia (insufficient oxygen reaching body tissues), exposure to contaminated suction equipment could trigger severe respiratory infections.
Proper suction equipment management becomes particularly vital for ventilator-dependent patients. The mechanical ventilator moves air in and out of lungs that cannot adequately perform gas exchange independently. When suctioning removes secretions to maintain airway patency, any introduction of bacteria from improperly maintained equipment can seed infections directly into compromised lungs.
Psychotropic Medication Monitoring Deficiencies
The facility failed to establish adequate monitoring systems for psychotropic medications prescribed to Resident 273, creating gaps in medication effectiveness evaluation and side effect surveillance.
Physician orders dated February 19-20, 2025, prescribed two medications—alprazolam (an anti-anxiety medication) at 0.25 mg twice daily and sertraline (an antidepressant) starting at 50 mg daily then increasing to 75 mg daily. Both medications listed identical indications: opsoclonus-myoclonus syndrome (OMS), a rare neurological disorder causing rapid, involuntary eye movements and muscle jerks.
When RN 4 reviewed the resident's records with inspectors on February 24, she acknowledged no behavioral monitoring existed for sertraline effectiveness. The nurse confirmed that monitoring documentation for alprazolam lacked accuracy and specificity in physician orders. Most problematically, both medications shared the same indication, making it impossible to determine which medication—if either—effectively addressed the resident's symptoms.
This monitoring failure undermines fundamental principles of psychotropic medication management in long-term care. When medications affect brain chemistry and behavior, facilities must track specific target symptoms to evaluate whether benefits justify continued use. Without clear behavioral markers, physicians cannot make informed decisions about dose adjustments, medication continuation, or potential alternatives.
The identical indications for two different drug classes raised additional clinical concerns. Alprazolam belongs to the benzodiazepine class and works by enhancing the calming neurotransmitter GABA, while sertraline is a selective serotonin reuptake inhibitor affecting different brain chemistry. While both might theoretically address anxiety components of neurological conditions, prescribing them simultaneously for the same indication requires careful monitoring to distinguish their individual effects and identify any problematic interactions.
LVN 6 demonstrated the confusion created by inadequate monitoring parameters. When asked which behaviors staff tracked for both medications, the nurse stated it was for OMS but couldn't identify specific behavioral targets. After reviewing medication administration records, LVN 6 mentioned monitoring "call out" behavior for alprazolam but acknowledged physician orders failed to specify which behaviors required monitoring for either medication.
Side effect monitoring posed equally concerning gaps. RN 4 confirmed no side effect surveillance existed for either medication. Alprazolam carries risks including sedation, respiratory depression, and paradoxical agitation—particularly concerning for pediatric patients. Sertraline can cause activation, sleep disturbances, and in rare cases, increased suicidal ideation in younger patients. Without systematic side effect monitoring, dangerous adverse reactions could go undetected until they escalated to serious harm.
Medication Storage and Expired Supplies
Inspectors identified multiple medication storage violations creating risks for unauthorized access and administration of expired or contaminated materials.
Resident 273's bedside table contained a 22-gram tube of mupirocin 2% ointment (used for skin infections) and a 60-gram tube of Venelex wound dressing. RN 4 explained both medications arrived with the resident at admission but should have been secured in locked medication treatment carts rather than remaining accessible at bedside. This storage failure violated the facility's policy requiring medications be stored safely and securely.
Unsecured medications at bedsides create multiple hazards in healthcare settings. Other residents or visitors could access medications not prescribed for them, leading to accidental ingestion or intentional misuse. For facilities serving pediatric populations, this risk intensifies as children and adolescents may lack judgment about medication dangers.
Similarly, Resident 4 had a six-ounce tube of Triad hydrophilic wound dressing with CMC (cellulose gum) stored at the bedside table. LVN 1 confirmed the wound care product arrived with the resident at admission but should have been secured in the medication treatment cart. While wound dressings may seem less hazardous than systemic medications, their unsecured storage still violates medication security protocols and creates potential for contamination or misuse.
Beyond storage violations, inspectors found expired supplies in three of six medication carts examined:
Medication Cart 2 contained eight packets of SurePrep protective wipe—a skin protectant used before applying wound dressings—that expired in August 2024. RN 1 acknowledged expired supplies required immediate removal and confirmed the protective wipes help wound dressings adhere properly to skin. Using expired skin protectants could reduce dressing effectiveness, potentially compromising wound healing.
Medication Cart 4 held an AG Cuffill pressure manometer that expired in November 2024. This device measures and regulates pressure in tracheostomy tube cuffs—the inflatable portions that seal airways to enable effective mechanical ventilation. RT 1 confirmed the expired equipment required immediate removal. Using expired pressure measurement devices creates risks for both over-inflation (causing tracheal tissue damage) and under-inflation (allowing secretions past the cuff into lungs).
Medication Cart 6 contained gastrostomy tube feeding extension sets with Enfit connectors expired since November 2024, plus 42 packets of SurePrep protective wipe expired since August 2024. LVN 3 verified expired supplies needed immediate removal and could lose effectiveness over time.
Additional Issues Identified
The inspection documented several additional safety concerns. During equipment use, a mechanical lift's battery died while transferring Resident 12 approximately one and a half feet above the wheelchair, requiring the CNA to manually return the resident to bed. The Maintenance Director confirmed staff should replace batteries after each use, indicating failures in equipment charging protocols outlined in facility policy requiring daily eight-hour minimum charging.
A refrigerator designated for hospital nutrition storage showed significant ice buildup along the back panel where prepared enteral feedings were stored. This ice accumulation can indicate temperature control problems that may compromise feeding formula safety.
The facility received a one-star staffing rating from CMS after failing to submit required staffing data for the quarter from July 1 through September 20, 2024. The Chief Executive Officer explained she submitted data in October 2024 but not in the required XML format, leading to rejection. Monthly staffing reports for September 2024 through January 2025 showed CNA hours fell below minimum requirements on multiple days, though the CEO noted excess nursing hours allowed nurses to assist with resident care.
Finally, inspectors found Resident 17's care plan failed to address physician orders for bilateral ankle-foot orthoses (AFOs) prescribed to maintain ankle alignment, promote range of motion exercises, and prevent contractures. The orders specified wearing the braces two hours on and two hours off from 8 a.m. to 10 p.m. with skin integrity checks before and after application. RN 1 acknowledged the care plan required revision to incorporate this important therapy.
The facility's CEO was informed of all findings on February 24, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Healthbridge Children's Hospital - Orange D/p Snf from 2025-02-24 including all violations, facility responses, and corrective action plans.
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