NOVATO, CA - Federal inspectors cited Novato Healthcare Center for serious medication administration failures during a December 2024 power outage that left nursing staff without access to electronic medical records for over two hours.
Undocumented Medication Administration Creates Safety Risk
The December 14-15, 2024 power outage exposed critical gaps in the facility's emergency preparedness protocols. During the 2.5-hour outage, nursing staff continued administering medications to residents but failed to document these administrations due to the electronic medical record system being offline.
The Director of Nursing confirmed that medications were administered on December 14 and 15 but were not documented unless there happened to be computer access at the time. This created a dangerous gap in the medical record that could lead to medication errors, including potential double-dosing or missed medications.
Licensed nurses working during the outage reported being unprepared for the situation. One Licensed Nurse stated they were "unaware of how medications would be passed if there was no access to the computer," while another confirmed management "was supposed to provide the LNs copies of the residents' MARs but had not."
Emergency Backup Systems Failed to Function
Federal regulations require nursing homes to maintain backup systems for critical operations like medication administration. The facility had established policies requiring backup computers and printers connected to emergency power supplies to generate paper medication administration records during outages.
However, the inspection revealed these backup systems were not implemented during the emergency. The Director of Nursing acknowledged that paper e-MARs were unavailable to nurses during the power outage because the entire system was down.
This failure violated the facility's own emergency preparedness policy, which specifically outlined procedures for creating paper medication records during power disruptions and internet service losses.
Lack of Leadership During Crisis
The inspection found significant leadership gaps during the emergency. Both the Administrator and Director of Nursing were absent from the facility during the power outage, leaving floor nurses without proper supervision or guidance.
Multiple staff members confirmed that neither administrator came to the facility during the crisis, despite the serious operational challenges. One nurse described the situation stating "there was no back-up for the staff" and expressed that staff "wished there had been a training on the process."
Medication Safety Standards and Risks
Proper medication documentation serves as a critical patient safety measure in nursing homes, where residents typically receive multiple daily medications for complex medical conditions. Without accurate records, healthcare providers cannot verify what medications were given, potentially leading to:
- Duplicate dosing if medications are administered multiple times - Missed doses of critical medications like heart or diabetes medications - Drug interaction risks when medications are given without knowledge of previous doses - Inability to track medication effectiveness or adverse reactions
Facility Assessment Requirements Not Met
The inspection revealed that Novato Healthcare Center's facility assessment failed to adequately address emergency medication management procedures. While the facility's assessment policy required descriptions of downtime procedures and medication management limitations, inspectors found no description of downtime procedures included in the facility's documentation.
Federal regulations mandate that nursing homes conduct comprehensive facility assessments to determine resources needed for both routine operations and emergency situations. These assessments must specifically address medication management capabilities and staff training needs.
Regulatory Response and Oversight
The Centers for Medicare & Medicaid Services classified this violation under federal regulation F658, which addresses emergency preparedness requirements for long-term care facilities. The citation noted "minimal harm or potential for actual harm" affecting many residents.
This violation highlights the importance of robust emergency preparedness in healthcare facilities, particularly regarding medication safety systems that protect vulnerable nursing home residents who depend on precise medication management for their health and wellbeing.
The facility must submit a plan of correction addressing staff training, backup system implementation, and leadership protocols during emergencies to maintain compliance with federal safety standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Novato Healthcare Center from 2025-02-24 including all violations, facility responses, and corrective action plans.
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