SANTA MONICA, CA - Federal inspectors documented serious medication safety violations at Beachwood Post-acute & Rehab that put residents at risk of overdose, drug interactions, and potentially fatal complications.
Unsecured Medications Left at Bedside
During a June 25, 2024 inspection, surveyors discovered two tubes of Diclofenac Sodium topical gel 1% and a box containing seven Salonpas Lidocaine 4% patches sitting openly on a resident's bedside table in an unlocked, visible area. The 89-year-old resident with severe cognitive impairment lay sleeping nearby while the prescription medications remained easily accessible.
The resident had no physician's order for either medication, according to electronic medical records. Licensed Vocational Nurse 9 acknowledged the family had brought the medications and was applying them to the resident without proper authorization.
The nurse identified multiple risks associated with having unauthorized medications in unsecured areas, including poisoning if consumed by confused residents who wander, overdose from improper dosing, dangerous drug interactions with prescribed medications, and allergic reactions that could necessitate emergency hospitalization or result in death.
Family Members Administering Prescription Drugs
The resident's daughter confirmed she had been applying the Diclofenac gel to her mother's foot and joints during visits every other day. She also placed Lidocaine patches on her mother's back when none were present. Neither the resident nor the responsible party had authorization for self-administration of medications.
The resident was already receiving multiple prescribed pain medications, including: - Orencia solution 125mg/ml administered weekly for rheumatoid arthritis - Tramadol 50mg tablets every 8 hours for severe pain - Extended-release Tylenol 650mg every 12 hours as needed
The combination of unauthorized topical pain medications with prescribed oral pain relievers created significant potential for drug interactions and overdose. Diclofenac belongs to the NSAID class of medications, which can interact dangerously with other drugs and cause serious side effects including kidney damage, heart problems, and gastrointestinal bleeding when used improperly.
Inadequate Medical Oversight
The resident's physician stated he had received a text message from facility staff 7-10 days prior regarding the use of both medications and had approved their use. However, he emphasized that licensed facility staff should have been administering the medications, not family members.
When inspectors requested documentation of this approval, the Director of Nursing was unable to provide any text messages or written orders from the physician authorizing use of either medication. Proper medication administration requires formal physician orders entered into the medical record system, not informal text communications.
Expired Medical Supplies and Medications
Inspectors identified additional medication safety failures throughout the facility. In the fourth-floor medication storage area, staff had left a half-used box of Safety-Lok Vacutainers available for blood collection despite an expiration date of April 30, 2023 - more than a year past expiration.
The Registered Nurse Supervisor acknowledged she was unaware of the expired blood collection equipment and stated it should be disposed of immediately. Using expired medical equipment creates risks of contamination and mechanical failure during blood draws, potentially causing injury to residents.
Staff also maintained expired Bisacodyl laxative tablets with an April 2024 expiration date in the medication supply area. Licensed Vocational Nurse 2 noted that residents could become ill if they received expired medications, as the therapeutic effectiveness diminishes over time.
Food Safety and Sanitation Violations
The inspection revealed widespread food safety violations that compounded health risks for medically vulnerable residents. In the main kitchen, inspectors found:
- Yellow sliced cheese with a February 23, 2024 expiration date - White bread expired since March 18, 2024 - Ranch dressing expired since February 7, 2024 - Large plastic containers with unlabeled food contents and no expiration dates
On nursing floors throughout the facility, staff stored 30 food items in unlabeled plastic containers without expiration dates, violating basic food safety protocols. The Dietary Supervisor acknowledged that residents could become ill if the kitchen was not maintained properly.
Infrastructure and Safety Hazards
Maintenance problems created additional safety risks. A leaking pipe under the kitchen dishwashing sink had created large puddles of water on the floor, presenting slip and fall hazards for staff. The Maintenance Supervisor stated the plumbing had not been serviced for approximately one year, despite the Dietary Supervisor reporting the leak one week prior to the inspection.
The facility's maintenance policy requires routine scheduled maintenance services and proper documentation of work orders, but staff could not provide records of recent plumbing repairs or maintenance schedules.
Emergency Communication System Failures
Inspectors documented a call light system failure that left a paralyzed resident unable to summon help. The resident with paraplegia, major depression, and muscle weakness required maximum assistance for toileting, hygiene, and personal care, yet could not reach the call light that had fallen under the bed.
The resident specifically asked inspectors to retrieve the call light, explaining the inability to reach it independently. A Certified Nurse Assistant acknowledged the call light was out of reach but claimed frequent room checks made this acceptable - contrary to facility policy requiring call lights remain within easy reach of all residents.
Regulatory Standards and Medical Implications
Federal nursing home regulations require strict medication management protocols to protect vulnerable residents. All medications must have proper physician orders, be administered only by licensed staff, and be stored securely to prevent access by confused or cognitively impaired residents.
The medication violations at Beachwood Post-acute created multiple layers of risk. Topical pain medications like Diclofenac can be absorbed systemically and interact with oral pain medications, potentially causing dangerous drops in blood pressure, kidney dysfunction, or central nervous system depression when combined improperly.
For residents with multiple chronic conditions and complex medication regimens, unauthorized drug administration by untrained family members represents a serious threat to patient safety. The facility's failure to maintain proper medical oversight and secure medication storage violated fundamental standards of nursing home care.
The inspection findings demonstrate systemic failures in medication management, food safety, facility maintenance, and emergency response systems that collectively endangered the health and safety of all 211 residents at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Beachwood Post-acute & Rehab from 2024-06-28 including all violations, facility responses, and corrective action plans.
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