RESEDA, CA - Federal inspectors documented repeated medication safety failures at Parkwest Healthcare Center after discovering nursing staff administered cardiac medications without conducting required safety checks for months.
Systematic Failure in Heart Medication Safety
During a May 2025 inspection, Centers for Medicare & Medicaid Services investigators found that nursing staff at the Reseda facility failed to check a resident's apical pulse before administering Flecainide, a heart rhythm medication that requires careful monitoring to prevent dangerous complications.
The violations occurred with Resident 62, who was admitted with atrial fibrillation and required Flecainide Acetate 50 mg twice daily. Physician orders specifically required staff to hold the medication if the resident's apical pulse dropped below 60 beats per minute - a critical safety parameter designed to prevent bradycardia.
Records show the pulse check was omitted 30 times over a two-month period: twice in March 2025, 17 times in April 2025, and 11 times in May 2025. Licensed Vocational Nurse 2 (LVN 2) told investigators he had "never taken an apical pulse for Resident 62, before administering Flecainide in the past."
Direct Observation Reveals Dangerous Practices
Inspectors witnessed the violation firsthand on May 21, 2025, during a medication pass observation. They observed LVN 2 take the resident's blood pressure and radial pulse, then asked if anything else needed checking. The nurse stated there was nothing else to check and administered the Flecainide before inspectors could intervene.
When questioned about the apical pulse requirement, LVN 2 initially claimed "there was no order to check the apical pulse." However, when shown the physician's order on the electronic medical record - highlighted in yellow with clear parameters - the nurse admitted he "overlooked the order on the computer."
The nurse explained that the computer system didn't prompt him to take an apical pulse before marking the medication as completed, and blamed the system for not having automatic safety checks in place.
Medical Significance of Pulse Monitoring
Flecainide is an antiarrhythmic medication that can significantly slow heart rate. Taking an apical pulse - measured with a stethoscope directly over the heart - provides the most accurate reading of heart rhythm and rate, especially critical for patients with existing cardiac conditions like atrial fibrillation.
When heart medications like Flecainide are given to patients with pulse rates below 60 beats per minute, it can cause bradycardia (dangerously slow heart rate), dizziness, and syncope (fainting). These complications can be particularly serious for elderly nursing home residents who may already have compromised cardiovascular systems.
The facility's Director of Nursing confirmed the importance of these safety checks, stating that "a resident could suffer complications such as bradycardia, dizziness, and syncope" when proper protocols aren't followed.
Systemic Medication Management Problems
The inspection revealed additional pharmaceutical safety issues beyond the pulse check failures. Investigators found problems with emergency medication kit management, discovering that two medication rooms had emergency kits that weren't properly replaced within the required 72-hour timeframe after being opened.
In the Subacute Station medication room, an emergency kit had been opened on May 14 but wasn't replaced by the time of inspection on May 19. Similarly, the Skilled Nursing Facility medication room had an emergency kit that was opened but lacked proper documentation and replacement procedures.
These emergency kits contain critical medications like antibiotics that may need immediate administration. When kits aren't properly maintained, life-saving medications may not be available when residents experience medical emergencies.
Storage and Labeling Violations
Additional medication safety concerns included improper storage practices. Inspectors found an unlabeled, unpackaged tablet in a medication cart drawer - a violation that creates risk for medication errors since staff cannot verify what medication it is or whether it has expired.
The facility's own policies require medications to remain in original packaging with proper labeling to ensure correct identification and expiration date verification.
Food Safety Risks for Vulnerable Residents
Beyond medication issues, the inspection documented food safety failures that could impact residents' health. Kitchen staff served pureed lemon crisp dessert to seven residents requiring texture-modified diets, despite the food being too thick according to International Dysphagia Diet Standardization Initiative guidelines.
The Dietary Supervisor confirmed the dessert failed the spoon tilt test, meaning it posed choking risks for residents with swallowing difficulties. Additional kitchen violations included unmarked food storage dates and incomplete temperature monitoring of foods on the serving line.
Administrative Documentation Errors
The facility also failed to maintain accurate medical records. Investigators found that one resident's file incorrectly indicated he had an Advance Directive when he did not. This type of documentation error can impact end-of-life care decisions and legal proceedings.
Facility Response and Corrective Actions
Following the inspection findings, the Director of Nursing implemented computer system changes to require apical pulse entry before cardiac medications can be marked as administered. This technological safeguard should prevent future occurrences of the pulse check omissions.
The facility's Pharmacist Consultant had previously recommended apical pulse monitoring for Flecainide administration in monthly pharmacy reviews, indicating awareness of the safety requirement that wasn't being followed by nursing staff.
Ongoing Monitoring and Compliance
These violations resulted in citations for failure to ensure residents are free from significant medication errors (F760), inadequate pharmaceutical services (F755), and improper medication storage (F761). While classified as causing minimal harm or potential for actual harm, the systematic nature of the violations over multiple months raises concerns about overall medication safety protocols.
The inspection findings highlight the critical importance of following prescribed medication parameters, especially for cardiac medications where improper administration can have serious consequences. Nursing facilities must ensure all staff understand and consistently follow safety protocols to protect vulnerable residents from preventable complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkwest Healthcare Center from 2025-05-23 including all violations, facility responses, and corrective action plans.
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