CHATSWORTH, CA - Federal health inspectors documented multiple medication safety violations at Chatsworth Park Health Care Center, including nurses administering a powerful IV antibiotic at 48% above the prescribed rate.
IV Medication Administration Error Exposed
During an April 21, 2025 inspection, surveyors observed a registered nurse administering Vancomycin, a high-risk antibiotic, to a resident with severe dementia and multiple health conditions. The nurse had set the IV flow regulator to 200 ml/hr instead of the prescribed 135 ml/hr - a significant deviation that could cause harmful side effects.
When questioned by inspectors, the registered nurse acknowledged the error, stating she "was wrong and should have dialed the flow regulator to 135 ml/hr because the order and label stated to administer at 135 ml/hr." The nurse further explained that "IV medications must be given at the prescribed rate to ensure it is not given too fast or too slow and to prevent side effects that could harm the resident."
The affected resident required dependence on supplemental oxygen and had diagnoses including dysphagia, heart failure, and unspecified dementia. The resident was classified as rarely or never understood and dependent on staff for all activities of daily living, making proper medication administration critical for their wellbeing.
Medical Implications of Rapid Vancomycin Administration
Vancomycin infusion rate errors can cause serious complications. When administered too rapidly, the antibiotic can trigger "red man syndrome," characterized by flushing, pain at the IV site, and dangerous drops in blood pressure. The medication's label specifically required infusion over two hours at 135 ml/hr, but the nurse's setting of 200 ml/hr would have completed the infusion in approximately 81 minutes.
According to the Director of Nursing, administering Vancomycin at the incorrect rate "is a medication error and giving Vancomycin too quickly can cause side effects such as pain in the IV site, flushing and redness or itching." These reactions can be particularly dangerous for elderly residents with compromised cardiovascular systems.
Expired Medication Storage Violations
Inspectors also discovered an unlabeled vial of Aplisol, a tuberculosis diagnostic medication, stored in the facility's medication refrigerator without proper dating. The opened vial lacked any indication of when it was first accessed, making it impossible to determine if the medication remained effective or had exceeded its 30-day shelf life.
The registered nurse present during the inspection acknowledged that "usually open Aplisol vials were good for 30 days and beyond 30 days it loses potency." She confirmed the vial was "considered expired and needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents."
Using expired Aplisol can produce inaccurate tuberculosis test results, potentially leading to false negatives or false positives. This could result in missed diagnoses of active tuberculosis infections or unnecessary treatment of residents who do not have the disease.
Infection Control Lapses
The facility failed to maintain proper infection control standards when staff allowed a resident's nasal cannula oxygen tubing to touch the floor. The Assistant Director of Nursing immediately recognized the contamination risk, stating the tubing "is already contaminated and can potentially introduce bacteria to Resident 66 which can lead to infection and had to be replaced immediately."
Floor surfaces in healthcare facilities harbor significant bacterial contamination from airborne microorganisms and materials transferred from shoes and equipment. When medical devices contact these surfaces, they can become vectors for introducing pathogens directly into vulnerable residents' respiratory systems.
Antibiotic Stewardship Program Failures
The facility's antibiotic monitoring program showed significant gaps when staff failed to complete required infection surveillance forms within the prescribed timeframe. For the same resident receiving IV Vancomycin, the infection control surveillance form should have been completed within 48-72 hours of starting the antibiotic but was not completed until 12 days later.
The Infection Control Nurse explained that surveillance forms using McGeer's criteria help determine whether residents truly meet the clinical definition for bacterial infection. When forms are delayed, physicians cannot make timely decisions about continuing or discontinuing antibiotics, potentially leading to unnecessary antibiotic exposure and increased risk of developing antibiotic-resistant infections.
Physical Environment Concerns
Six resident rooms at the facility failed to meet federal space requirements of 80 square feet per resident. Rooms 108, 109, 208, 209, 215, and 216 provided between 73.2 and 79.2 square feet per resident, falling short of the 80 square foot minimum.
While the facility submitted a waiver request and inspectors noted that residents had sufficient space to move freely with adequate room for beds and care equipment, the undersized rooms represent ongoing non-compliance with federal standards designed to ensure adequate space for safe nursing care and resident privacy.
Regulatory Standards and Expectations
Federal regulations require nursing homes to follow physicians' orders precisely when administering medications, including exact dosages and infusion rates. The facility's own policy mandated that "medication and/or fluids shall be administered as prescribed by the attending physician" and required verification that container labels match prescriber orders.
Multi-dose vials must be properly labeled with opening dates to track expiration timelines and prevent inadvertent use of degraded medications. The facility's policy specifically stated that "opening a vial triggers a shortened expiration date that is unique for that product" and required both opening dates and expiration dates to be recorded.
Antibiotic stewardship programs are federally mandated to combat the growing threat of antibiotic resistance. These programs require systematic monitoring of all antibiotic use through surveillance forms that help clinicians determine whether continued treatment is medically justified.
The violations identified at Chatsworth Park Health Care Center reflect systemic breakdowns in medication safety protocols, infection control procedures, and antibiotic monitoring systems that collectively compromise resident safety and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chatsworth Park Health Care Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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