LONG BEACH, CA - State inspectors documented serious medication administration errors and inadequate wound care protocols at Shoreline Healthcare Center during an April 2025 inspection, with violations affecting multiple residents and raising concerns about patient safety oversight.
Critical Medication Administration Failures
The facility's medication error rate reached 9.68%, nearly double the allowable 5% threshold, with inspectors observing significant errors during routine medication administration. Two residents received incorrect medications that posed serious health risks.
Resident 377 was prescribed morphine sulfate extended-release (ER) 15mg every 12 hours for pain management following genitourinary surgery. However, the facility administered immediate-release (IR) morphine instead. Extended-release formulations provide sustained pain relief over 12-hour periods, while immediate-release medications only provide short-term relief. This error resulted in inadequate pain control, forcing the resident to request additional breakthrough pain medication multiple times daily. Pain levels consistently remained between 7-10 on a 10-point scale, indicating severe discomfort.
The medication mix-up occurred because the pharmacy delivered the wrong formulation, but nursing staff failed to verify the medication against physician orders before administration. When questioned, a licensed vocational nurse acknowledged that "the label on the morphine sulfate bubble pack read IR 15 mg, which did not match Resident 377's medication order that read morphine sulfate ER 15 mg."
Resident 429 experienced a different but equally concerning error. The resident was prescribed benazepril 20mg for hypertension but received 40mg tablets instead - double the prescribed dose. This error creates risk for hypotension, a dangerous drop in blood pressure that can cause weakness, dizziness, and increased fall risk. Additionally, nursing staff incorrectly administered vitamin C 500mg instead of the prescribed calcium supplement.
These errors violated fundamental medication safety protocols. Healthcare facilities must follow the "Six Rights of Medication Administration": right patient, right drug, right dose, right route, right time, and right documentation. The facility's own policy requires nurses to verify medications against orders before administration, but this critical safety step was not followed.
Severe Wound Care Management Deficiencies
Inspectors identified alarming failures in wound assessment and treatment that allowed preventable deterioration of resident conditions.
Resident 35 was admitted with a left heel blister that progressively worsened due to inadequate monitoring and delayed physician notification. The resident arrived from acute care with documentation of a 6cm by 6cm stage 2 wound, but facility assessments were inconsistent and incomplete.
The wound was initially classified as a blister, then reclassified as a deep tissue injury (SDTI) with purple tissue, and ultimately became an unstageable pressure injury measuring 6.5cm by 7cm with 75% eschar coverage. Eschar is dead tissue that impedes healing and can mask the true extent of underlying damage.
Critical breakdowns occurred when nursing staff failed to notify physicians of wound deterioration. A treatment nurse admitted during interviews: "I was upset with myself because I did not perform a [change of condition] assessment and notify the physician of Resident 35's decline in wound appearance." The nurse acknowledged this failure could have delayed necessary treatment interventions.
The resident's family member expressed frustration, stating the left heel wound was "getting worse." During inspection observations, Resident 35 was "lying in bed crying in pain, saying her left foot hurt" and reporting chills, which can indicate systemic infection.
Resident 57 developed a stage 4 pressure injury despite being admitted with intact skin. The wound progression was documented from initial redness in November 2024 to moisture-associated skin damage, then an unstageable injury requiring debridement, and finally a full-thickness stage 4 wound extending into muscle and bone.
This progression represents a fundamental failure of pressure injury prevention. Stage 4 pressure injuries are serious wounds that can take months to heal and carry significant infection risk. The Director of Nursing acknowledged that "it is not normal for a resident with intact skin on admission to develop a stage four pressure injury."
Medical protocols require systematic wound assessment, appropriate pressure relief measures, and timely physician notification when changes occur. The facility's policy mandates weekly wound documentation and immediate reporting of deterioration, but these standards were not followed.
Understanding the Medical Significance
These violations have serious implications for resident health and safety. Medication errors can cause therapeutic failures, adverse drug reactions, and life-threatening complications. When pain medications are incorrectly formulated, residents experience unnecessary suffering and may develop tolerance requiring higher doses.
Wound care failures are particularly concerning because pressure injuries are largely preventable with proper care protocols. Once established, these wounds create infection risks, cause significant pain, and can lead to sepsis - a potentially fatal systemic infection. The progression from intact skin to stage 4 pressure injury represents multiple missed opportunities for intervention.
Industry standards require comprehensive admission assessments, regular monitoring, and immediate response to condition changes. Facilities must maintain accurate documentation to track resident progress and ensure continuity of care. When these systems fail, residents face increased morbidity and potential mortality risks.
Additional Issues Identified
Beyond the major violations, inspectors documented several other concerning practices. The facility failed to provide required social services assessments for residents with trauma histories, including those with post-traumatic stress disorder and assault victims. These assessments are essential for identifying triggers and ensuring appropriate psychological support.
Dietary service violations included improper food preparation for residents with modified texture diets, potentially creating choking hazards. Kitchen staff failed to follow standardized recipes and portion guidelines, serving ground-texture residents smaller portions and incorrect food consistencies.
Pharmaceutical service deficiencies included inadequate emergency medication tracking, missing witness signatures on controlled substance disposal, and unauthorized medication crushing without physician orders. These practices create opportunities for medication diversion and dosing errors.
The facility also failed to maintain accurate medical records for restorative nursing services, compromising the ability to track resident functional improvements and therapy compliance.
These systemic issues suggest broader challenges with staff training, policy implementation, and quality oversight that extend beyond individual incidents to organizational culture and management practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shoreline Healthcare Center from 2025-04-18 including all violations, facility responses, and corrective action plans.
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