WOODLAND HILLS, CA - A skilled nursing facility operated by Motion Picture and Television Fund has been cited for significant medication administration failures during an April 2025 health inspection, including administering discontinued medications, failing to follow prescribed schedules, and lacking proper monitoring protocols for high-risk drugs.
Discontinued Medication Administered for Months Without Authorization
The most concerning violation involved a 58-day-old pressure injury patient who received an antibiotic ointment daily for nearly two months after the medication order had been discontinued. According to inspection records, Licensed Vocational Nurse 1 (LVN 1) administered mupirocin ointment to Resident 39's sacral pressure wound without verifying an active physician's order.
The resident, who was diagnosed with neurocognitive disorder with Lewy bodies and required complete assistance for all daily activities, had a stage two pressure injury on the lower back. While the original mupirocin order was discontinued on February 12, 2025, the medication remained in the treatment cart and continued being applied through at least April 10, 2025.
During the inspection, LVN 1 acknowledged applying the discontinued medication multiple times that week, stating she "just saw the mupirocin ointment in the cart, grabbed it, and applied it to Resident 39." The nurse admitted she thought an order existed but had not carefully reviewed the treatment orders before administration.
The facility's Director of Long-Term Care confirmed that discontinued medications are removed from use for specific reasons - either because they are no longer effective or a different treatment has become more appropriate. Continuing an unauthorized antibiotic treatment creates significant risks. When topical antibiotics are used without proper medical oversight, they can delay wound healing, contribute to antibiotic resistance, or mask signs of infection that require different interventions. For pressure injuries, using the wrong treatment protocol can prevent proper healing and potentially lead to wound deterioration.
Critical Timing Violations for Seizure and Diabetes Medications
Two residents with serious medical conditions received their medications more than an hour outside the prescribed administration window, violating federal regulations and facility policies. Both incidents occurred on April 10, 2025, when LVN 1 administered 9 a.m. scheduled medications at approximately 7:30 a.m.
Resident 66, diagnosed with seizure disorder and paraplegia, received anticonvulsant medications including lacosamide and levetiracetam at 7:31 a.m. instead of the scheduled 9 a.m. time. The resident also received eye medications and an antihistamine during this early administration. Anti-seizure medications require precise timing to maintain therapeutic blood levels. Administering these medications outside the prescribed schedule can cause fluctuations in drug concentration, potentially triggering breakthrough seizures or increasing side effects.
Similarly, Resident 19, who has diabetes and dementia, received metformin and other medications at 7:43 a.m. For diabetic patients, medication timing is critical for blood sugar control. Metformin works in coordination with meal times and the body's natural glucose production cycles. Early administration can lead to hypoglycemia, especially if meals are not adjusted accordingly, or hyperglycemia if the medication's effect wears off before the next scheduled dose.
The facility's electronic medication administration record system prevented the nurse from documenting these early administrations until 8 a.m., creating additional documentation discrepancies. The Director of Pharmacy emphasized that the one-hour window before and after scheduled times exists for specific clinical reasons, and deviating beyond this window requires physician authorization and documentation.
Absence of Monitoring Protocols for High-Risk Medications
The inspection revealed systematic failures to monitor residents receiving long-term antibiotic therapy and antiplatelet medications, despite these drugs being classified as high-risk by federal guidelines.
Resident 21, receiving twice-weekly azithromycin for pneumonia prophylaxis, had no monitoring orders for adverse effects despite being on this antibiotic regimen long-term. Prolonged antibiotic use, particularly in elderly populations, increases risks of cardiac arrhythmias, including the potentially fatal torsade de pointes. The medication's manufacturer specifically warns that elderly patients require particular caution due to increased susceptibility to cardiac rhythm disturbances. Without regular monitoring, serious adverse effects could go undetected until they become life-threatening emergencies.
Resident 4 had a standing order for amoxicillin labeled as "PRN" (as needed) for dental procedures, though the medication had only been used once in the previous year. The Nurse Practitioner confirmed this should have been written as a one-time order rather than PRN, as the current ordering practice increases the risk of inappropriate administration. Additionally, no monitoring protocol existed to detect potential allergic reactions or gastrointestinal effects common with amoxicillin use.
Most concerning was Resident 338, who received dual antiplatelet therapy with both aspirin and clopidogrel for stroke prevention but had no bleeding monitoring protocols in place. Dual antiplatelet therapy significantly increases bleeding risk, with manufacturer warnings specifically highlighting life-threatening and fatal bleeding as the most common adverse reaction. Standard medical practice requires regular monitoring of patients on dual antiplatelet therapy through clinical assessments for bruising, bleeding gums, blood in stool or urine, and periodic laboratory testing of blood counts.
Gastrostomy Tube Medication Administration Failures
The inspection also documented improper administration techniques for residents receiving medications through gastrostomy tubes. Resident 86's medications were not properly flushed between different drugs, creating risk for tube obstruction and drug interactions. When medications are administered through feeding tubes, each medication must be separated by water flushes to prevent physical and chemical incompatibilities. Failure to flush between medications can cause drugs to precipitate and clog the tube, requiring surgical replacement. Additionally, direct contact between incompatible medications can alter their effectiveness or create harmful compounds.
Additional Issues Identified
Beyond the major violations detailed above, inspectors noted several systemic issues with medication management at the facility. The pharmacy notification system for discontinued medications failed to ensure prompt removal from treatment carts, allowing discontinued drugs to remain accessible to staff. Multiple nurses were unaware of proper procedures for documenting early medication administration or obtaining necessary physician approvals for schedule changes. The facility's medication error rate during the inspection period reached 25 percent, five times higher than the federal maximum allowable rate of 5 percent.
Staff interviews revealed confusion about medication administration policies, with nurses believing verbal communications with providers were sufficient for schedule changes without formal order modifications. The facility's own policies clearly required written physician orders for all medication administration, including any timing adjustments outside standard windows.
Industry Standards and Medical Implications
These violations represent fundamental breakdowns in medication safety protocols that form the foundation of skilled nursing care. The "Six Rights of Safe Medication Administration" - right medication, right dose, right patient, right route, right time, and right documentation - are universally recognized standards that were repeatedly violated at this facility.
For vulnerable nursing home residents with complex medical conditions, medication errors can have severe consequences. Elderly patients often have reduced kidney and liver function, affecting how their bodies process medications. They frequently take multiple drugs that can interact dangerously when administration schedules are altered. Cognitive impairments common in this population mean residents cannot always communicate adverse effects they are experiencing, making proper monitoring protocols essential.
The failure to maintain proper medication protocols is particularly concerning given the residents' vulnerability. Many had severe cognitive impairments and could not advocate for themselves or report medication-related problems. The facility's role as guardian of these residents' pharmaceutical care makes these violations especially serious breaches of trust and professional responsibility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Motion Picture and T.v. Hosp D/p Snf from 2025-04-11 including all violations, facility responses, and corrective action plans.
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