The resident at Western Convalescent Hospital needed the antibiotic Ertapenem to treat a urinary tract infection. The doctor ordered one gram every 24 hours through September 10.
On September 8 at 5:30 a.m., staff hung a 100-cubic-centimeter bag of the antibiotic. By 11:15 a.m. — nearly six hours later — 40 cubic centimeters remained in the bag, still dripping but not infusing into the resident.
The Assistant Director of Nursing told inspectors the medication should have been completely infused by 6:30 a.m., just one hour after it was hung.
"Failure to monitor the IV Ertapenem was completely infused and ensure the complete dose was administered will not treat the infection," the nursing supervisor acknowledged.
The resident couldn't communicate the problem. Medical records show the person had no speech following a stroke, was rarely or never understood, and rarely or never understands others. Staff provided total assistance with toileting, personal hygiene, and bathing.
The incomplete antibiotic dose was just the beginning.
The next day, September 9, inspectors returned at 11:05 a.m. to check on the resident's IV access. They found the saline lock needle tip had dislodged completely from the resident's vein and was lying on the skin of the back of the person's right hand.
The registered nurse on duty seemed unaware of the problem. She told inspectors the resident had received the IV antibiotic the night before "and there was no report of any problem."
When inspectors pointed out the dislodged needle, the nurse acknowledged that "a patent saline lock should be in the vein to administer IV medications."
The facility's own care plan, written when the antibiotic treatment began on September 2, set clear expectations that weren't met. The plan required registered nurses to "infuse the fluids and/or medications as ordered" and "observe the IV site frequently for signs and symptoms of complications such as redness, swelling, pain, drainage and leakage."
The goal was for the resident's "IV access will be maintained and be free of complications for successful completion of therapy."
Instead, the resident received incomplete doses of medication critical for treating the infection.
The resident had been admitted to Western Convalescent Hospital twice — first on an undisclosed date, then readmitted with multiple serious conditions including the urinary tract infection, difficulty swallowing following a stroke, and type 2 diabetes.
Federal inspectors noted the failures had "the potential for the infection will not be resolved due to an incomplete dose of antibiotic medication administered" and "the potential to cause infection on the IV site and the potential for a missed antibiotic dose."
The facility's own policy, updated in March 2023, requires registered nurses and IV-certified licensed vocational nurses to "perform IV infusions according to state law and facility policy." The policy specifically states nurses "should monitor the venous access site frequently for signs and symptoms of complications."
Yet over two consecutive days, staff failed to ensure a vulnerable resident received prescribed antibiotic treatment. On the first day, they hung medication that didn't infuse. On the second, the IV access had failed completely without anyone noticing.
The resident remained dependent on staff for the most basic care — unable to speak, rarely understood, and requiring total assistance with personal needs. When the IV system designed to deliver life-saving medication failed, the resident had no way to alert anyone to the problem.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Western Convalescent Hospital from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Western Convalescent Hospital
- Browse all CA nursing home inspections