LOS ANGELES, CA - Federal inspectors found serious deficiencies at Skyline Healthcare Center on Rowena Avenue, including inadequate pain management for residents and improper staffing qualifications that put patient safety at risk.
Resident Faced Severe, Unmanaged Pain
The most significant violation centered on a resident with an artificial hip joint who reported experiencing severe pain rated at 9 out of 10 on the standard pain scale for over two months. Despite having physician-ordered pain medications available, nursing staff failed to adequately address the resident's suffering or communicate concerns to medical providers.
During multiple observations over four days in April, inspectors found the resident lying in bed, moaning with facial grimacing and labored breathing. "I need pain medication. It takes hours to get my pain medications. My legs and arms hurt," the resident told inspectors. The resident explained that pain had persisted since admission in February and that current medications were ineffective.
The facility's Licensed Vocational Nurse acknowledged the resident requested pain medication every two to three hours, though it was only ordered every four hours. The nurse admitted the resident's pain was not controlled and had not been reported to the attending physician or discussed with the interdisciplinary care team.
Medical Protocols Ignored
Standard nursing practice requires healthcare providers to assess pain regularly and communicate concerns about uncontrolled pain to physicians promptly. Pain management in nursing homes must follow established protocols that include monitoring effectiveness of interventions and adjusting treatment plans when residents report inadequate relief.
The resident's condition prevented participation in prescribed physical therapy sessions. A Restorative Nurse Assistant confirmed the resident "always refuse to sit or stand as ordered by the physician because Resident 1 has continuous pain and cannot participate in RNA exercises." However, this critical information was documented but not communicated to licensed nursing staff or physicians.
When the resident's physician was contacted during the inspection, he stated: "The resident has pain due to orthopedic device and artificial right hip joint and the facility staff did not notify me of the resident's pain status." The doctor immediately ordered stronger pain medication and requested a pain management consultation, indicating proper medical intervention was readily available but not pursued by facility staff.
Unqualified Staff in Key Position
Inspectors discovered another serious safety concern when they found a certified nursing assistant had been working as the facility's case manager for over a decade without proper qualifications. The position requires complex clinical assessments and care coordination responsibilities typically requiring advanced nursing credentials or specialized training.
The employee, who has served as case manager since 2014, admitted she "has not had any formal training as a case manager and does not have the required qualifications." Her responsibilities included conducting pre-admission clinical assessments, coordinating patient care, and determining resource utilization for residents' medical needs.
The facility's job description for case managers specifies requirements including current state licensure and preferably a bachelor's degree in healthcare. The Director of Nursing expressed shock upon learning of the staffing issue, stating it was "dangerous because Case Manager 1 is not qualified to assess residents and to coordinate residents' care to meet specific needs."
Impact on Patient Care Quality
Uncontrolled pain significantly affects residents' physical and psychological wellbeing. Chronic pain can lead to decreased mobility, social isolation, depression, and reduced participation in rehabilitation activities essential for maintaining independence. In this case, the resident's pain directly prevented engagement with prescribed physical therapy, potentially compromising recovery and functional improvement.
The staffing violation created systemic risks for all residents. Case managers play crucial roles in ensuring residents receive appropriate care levels and services. Inadequate qualifications in this position could result in inappropriate admissions, insufficient care planning, and poor coordination between healthcare providers.
The Director of Nursing acknowledged both violations posed risks to residents, stating the unqualified case manager situation "can lead to residents' lower quality of care" and that the resident with uncontrolled pain "suffered harm due to pain experienced."
Additional Issues Identified
The inspection revealed the facility's own policies were not being followed. Their Pain Management policy requires staff to evaluate and report residents' pain medication use and consider additional consultative support when pain is complex or unresponsive to standard interventions. Similarly, their Staff Competency Assessment policy mandates validation of licensure and competency evaluations within 90 days of employment.
Both violations received "minimal harm" severity ratings, indicating inspectors found actual harm occurred or immediate risk to residents existed. The facility must submit corrective action plans addressing how they will improve pain management protocols and ensure all staff meet position requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyline Healthcare Center - La from 2025-04-14 including all violations, facility responses, and corrective action plans.
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