LOS ANGELES, CA - Federal inspectors found Westwood Post Acute Care violated patient privacy regulations and failed to properly administer required vaccinations during an April 2025 inspection, putting vulnerable residents at risk for serious infections.
Unauthorized Disclosure of Protected Health Information
The most serious violation involved the unauthorized sharing of a paraplegic resident's protected health information with an independent placement liaison who had no legitimate access to the medical records. The resident, identified as Resident 48, was a cognitively intact individual with complete paraplegia who required extensive assistance with daily activities.
According to the inspection report, an independent liaison who was not employed by the facility obtained the resident's medical records from a hospice company without proper authorization. The liaison then used this confidential information to arrange for the resident's discharge to hospice care at home, claiming the resident was "unhappy with the facility and wanted to go home."
However, the inspection revealed critical gaps in this process. The liaison admitted she "did not personally speak with the resident, did not get his consent, or confirm that Resident 48 was unhappy with the facility" before arranging the discharge. Despite having no medical background and no direct contact with the patient, the liaison proceeded to coordinate medical care decisions based solely on reading protected health information she should not have had access to.
The violation became more concerning when the facility's Vice President of Operations stated he had never heard of the liaison and confirmed she "was not an employee of the facility or the corporation, and has no relationship with the company." This raises serious questions about how an unauthorized third party gained access to confidential medical records and was able to influence patient care decisions.
Medical Significance of Privacy Violations
Patient privacy protections exist for fundamental medical and ethical reasons. When unauthorized individuals access medical records, several critical risks emerge that can directly impact patient health outcomes.
Protected health information includes not only basic demographics but also detailed medical conditions, treatment plans, and care decisions. In this case, the resident's paraplegia status, cognitive capacity, and care requirements were all exposed to an unauthorized party. This information could be used to discriminate against the patient or influence care decisions without proper medical evaluation.
The unauthorized disclosure also disrupted the established care team relationships. The resident had been receiving appropriate care for his complex medical needs, including management of his complete paraplegia and hypertension. When an outside party with no medical training began making discharge arrangements without consulting the patient or his medical team, it created potential for medical complications and continuity of care issues.
Healthcare facilities are required to maintain strict controls over who can access patient information, ensuring only authorized personnel involved in direct care, treatment, or payment can review medical records. This case represents a breakdown in these essential safeguards.
Critical Vaccination Compliance Failures
Inspectors identified systematic failures in the facility's vaccination program that left residents vulnerable to preventable infections. Two cognitively intact residents, including one with diabetes and another with multiple chronic conditions, were not offered required pneumonia and COVID-19 vaccinations upon admission as mandated by facility policy.
The facility's Infection Prevention Nurse acknowledged that both residents "should have been offered/consented and/or declination form for the PNA vaccine at the times of admission to prevent an infection such as PNA which may lead to hospitalization." The same failure occurred with COVID-19 vaccinations, with documentation showing consent forms were only obtained during the inspection process, months after admission.
This represents a systemic breakdown in the facility's vaccination screening process. According to facility policy, residents should be screened immediately upon admission using multiple verification methods including the California Immunization Registry and the facility's internal vaccination network. Staff should then obtain either consent or declination forms based on the resident's current vaccination status.
Health Consequences of Vaccination Delays
The medical implications of delayed vaccinations in nursing home settings are severe and well-documented. Pneumonia represents one of the leading causes of hospitalization and death among elderly residents in long-term care facilities. Adults over 65 face significantly higher risks of serious complications from pneumococcal infections, including bloodstream infections, meningitis, and severe pneumonia requiring intensive medical intervention.
COVID-19 presents even greater risks in congregate care settings where vulnerable populations live in close proximity. Nursing home residents have consistently experienced the highest rates of severe illness, hospitalization, and death from COVID-19 throughout the pandemic. Vaccination remains the most effective prevention strategy, particularly for residents with underlying conditions like diabetes, which was present in one of the affected residents.
The facility's own policies recognize these risks, stating that vaccinations should be offered according to Centers for Disease Control and Prevention recommendations to prevent infections that may lead to hospitalization. The failure to implement these protocols upon admission created an unnecessary window of vulnerability for residents who relied on the facility to protect their health.
Delayed vaccination also affects community health within the facility. When residents remain unvaccinated, they can potentially transmit infections to other vulnerable residents, staff members, and visitors, creating outbreak conditions that have historically devastated nursing home populations.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive vaccination programs that include immediate screening upon admission, clear documentation of vaccination status, and timely administration of recommended vaccines. The Centers for Disease Control and Prevention provides specific guidance for pneumococcal and COVID-19 vaccinations in long-term care settings, emphasizing the critical importance of preventing delays.
Standard practice requires facilities to verify vaccination status through multiple sources, including state immunization registries, previous healthcare providers, and family members. When vaccination status cannot be verified, facilities should err on the side of protection by offering vaccinations rather than assuming residents are current.
The privacy violations also contradict established healthcare protocols. HIPAA regulations specifically protect individually identifiable health information and limit disclosure to authorized personnel involved in treatment, payment, or healthcare operations. Any sharing of protected information requires either patient authorization or specific legal justification under federal privacy rules.
Additional Issues Identified
Beyond the major violations, the inspection documented several concerning patterns in facility operations. The privacy breach involved complex arrangements between the facility, a hospice company, and an unauthorized liaison, suggesting potential gaps in vendor management and information security protocols.
The vaccination failures affected multiple residents and involved systemic breakdowns in admission procedures rather than isolated incidents. This pattern indicates potential deficiencies in staff training, quality assurance processes, and compliance monitoring systems.
The facility's response during the inspection also raised questions about oversight and accountability, particularly regarding how unauthorized third parties gained access to confidential patient information and influenced care decisions.
These violations occurred during a period when nursing homes faced increased scrutiny regarding infection control and patient rights, making compliance with basic safety and privacy requirements even more critical for protecting vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Post Acute Care from 2025-04-04 including all violations, facility responses, and corrective action plans.
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