SANTA MONICA, CA - A state inspection at The Rehabilitation Center of Santa Monica found critical failures in monitoring a cognitively impaired resident at high risk for wandering, along with inadequate wound care and missing identification protocols that compromised resident safety.
Vulnerable Resident Left Without Proper Supervision
The April 4, 2025 complaint investigation centered on a resident with severe cognitive impairment from Lewy body dementia, a progressive brain disorder that affects thinking, movement, and behavior. The resident, who also had Parkinson's disease and major depression, required maximum assistance for all daily activities and lacked the mental capacity to make medical decisions.
Despite physician orders requiring staff to monitor the resident's whereabouts every two hours and use a Wanderguard bracelet to prevent unauthorized departures, inspectors discovered significant gaps in the monitoring system. A certified nursing assistant caring for the resident told inspectors he "was not given any information from the previous shift or anyone else that the resident was an elopement risk" and didn't understand the purpose of the safety bracelet on the resident's wrist.
The communication breakdown extended beyond individual staff members. The facility's assignment sheets failed to properly assign the resident to any specific caregiver, leaving responsibility unclear. The director of nursing acknowledged that critical safety information should have been communicated during staff huddles but admitted this hadn't occurred.
Missing Identification Creates Additional Safety Risks
Compounding the supervision failures, inspectors observed the resident without any identification wristband on multiple occasions throughout the inspection day. Staff members confirmed the resident should have been wearing an ID band for safety purposes, yet none was present.
The absence of proper identification is particularly dangerous for residents with severe cognitive impairment who cannot reliably communicate their own identity or medical needs. Without an ID band, staff cannot quickly verify they're administering the correct medications or treatments to the right person - a fundamental safety protocol in healthcare settings.
Untreated Wound Violates Physician Orders
The inspection also revealed the facility failed to follow physician orders for treating a skin tear on the resident's right wrist. Despite active medical orders requiring the wound to be cleansed with saline, covered with xeroform dressing, and protected with a dry dressing, inspectors found the wound "scabbed over and open to air" without any covering.
When questioned, the licensed vocational nurse stated she "did not know if the wound should be covered" and deferred responsibility to a treatment nurse. The director of nursing initially claimed the wound didn't need covering since it appeared healed, but then acknowledged that existing physician orders should still be followed.
Why These Violations Pose Serious Health Risks
For residents with Lewy body dementia, proper supervision is essential for preventing life-threatening situations. These individuals often experience confusion, hallucinations, and impaired judgment that can lead them to wander into dangerous areas or leave the facility entirely. Without consistent monitoring and functioning alert systems, such residents face risks of falls, exposure to extreme temperatures, traffic accidents, or becoming lost and unable to find help.
The wound care violations, while appearing less severe, still present significant concerns. Skin tears in elderly residents heal slowly due to thinning skin and reduced circulation. Leaving wounds uncovered increases infection risk, particularly for residents who cannot maintain proper hygiene independently. Additionally, uncovered wounds are more susceptible to re-injury from bumping or scratching, potentially leading to larger wounds, infections, or chronic non-healing ulcers.
Proper identification protocols exist to prevent medication errors, which cause thousands of deaths annually in healthcare facilities. For a resident with multiple serious conditions requiring various medications, receiving the wrong drugs or doses could trigger severe reactions, worsen existing conditions, or create dangerous drug interactions.
Additional Issues Identified
The inspection revealed broader systemic problems with the facility's safety protocols. Staff training appeared inadequate, with newer employees unfamiliar with basic safety equipment like Wanderguard bracelets. The facility's own policies requiring resident identification systems and proper wound care procedures were not being followed. Communication systems meant to relay critical safety information during shift changes and daily huddles were failing to function effectively.
The inspection findings indicate these weren't isolated incidents but rather symptoms of larger organizational failures in training, communication, and quality assurance systems designed to protect vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center of Santa Monica from 2025-04-04 including all violations, facility responses, and corrective action plans.
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