A North Hollywood nursing home faces federal citations for multiple medication safety violations that put vulnerable diabetic residents at risk of serious health complications.
Critical Medication Administration Failures
Federal inspectors documented systematic medication errors at Sherman Village HCC during a September 2024 inspection, revealing dangerous patterns in insulin management and drug administration protocols. The violations centered on improper injection site rotation, administration of expired medications, and incorrect dosing schedules.
Insulin Site Rotation Violations Across Multiple Residents
The most widespread violation involved nursing staff's failure to properly rotate insulin injection sites for diabetic residents. Federal regulations and manufacturer guidelines require rotation of injection sites to prevent lipodystrophy - a condition where skin becomes thickened or develops lumps that can interfere with insulin absorption.
Inspectors found that Resident 61, who has severely impaired cognitive abilities and requires insulin for Type 2 diabetes, received multiple insulin injections in the same abdominal areas over consecutive days. Records showed injections administered repeatedly in the right upper quadrant of the abdomen on August 7th and 8th, violating the facility's own policy requiring site rotation within different body regions.
Similar patterns emerged with Resident 60, who was prescribed both insulin and Lovenox (a blood thinner). Documentation revealed consecutive injections in identical locations, with both medications administered in the left lower quadrant of the abdomen on the same dates. This practice increases risks of skin damage and medication absorption problems.
The facility's Director of Nursing acknowledged these failures during interviews, stating that staff "should have rotated the insulin administration sites to prevent lipodystrophy and cutaneous amyloidosis on residents." The DON confirmed that failing to rotate injection sites constituted medication errors that could harm residents.
Dangerous Administration of Expired Insulin
Perhaps most concerning was the discovery that Resident 85 received 25 doses of expired Humulin R insulin over multiple weeks. Federal inspectors found an opened insulin vial in the medication cart that had expired on a specific date, yet nursing staff continued administering doses from this vial for days afterward.
Multiple Licensed Vocational Nurses (LVNs) were involved in these administration errors, with LVN 7 giving 12 expired doses, LVN 8 administering 7 doses, and several other nurses contributing to the total. The facility's own policy states that opened Humulin R insulin must be discarded within 31 days of opening, but staff failed to follow this protocol.
During interviews, nursing staff confirmed the serious risks posed by expired insulin. LVN 5 explained that "administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 85 by causing high or low blood sugar levels, leading to coma, hospitalization or even death."
Expired insulin loses its potency and effectiveness over time, meaning residents may experience dangerous blood sugar fluctuations. For diabetic residents, unstable glucose levels can trigger diabetic ketoacidosis, severe hypoglycemia, or other life-threatening complications requiring immediate medical intervention.
Medication Overdose Through Incorrect Dosing
Inspectors also documented a potentially dangerous overdose situation involving Resident 548, who was prescribed Metoprolol Succinate ER - an extended-release blood pressure medication designed for once-daily dosing. Despite manufacturer guidelines specifying single daily administration, nursing staff had been giving this resident the medication twice daily since the prescription began.
The medication's extended-release formulation is specifically designed to provide 24-hour blood pressure control with one dose. Administering it twice daily effectively doubles the intended dose, potentially causing dangerously low blood pressure and heart rate.
LVN 4 recognized this error during the inspection, stating that "administering Metoprolol Succinate ER tablet 24 hour 50 mg tablet twice a day was considered overdosing and can cause harm by lowering the blood pressure and heart rate to dangerous levels for Resident 548."
Excessive blood pressure medication can cause falls, dizziness, fainting, and cardiovascular complications in elderly residents who may already have compromised circulation and heart function.
Medical Implications and Health Risks
These medication errors create multiple pathways for serious resident harm. Improper insulin injection techniques can lead to lipodystrophy, where repeated injections in the same area cause skin changes that interfere with insulin absorption. This creates unpredictable blood sugar control, potentially triggering dangerous glucose fluctuations.
When injection sites become lipodystrophic, insulin absorption becomes erratic and unreliable. Residents may experience unexpected blood sugar spikes or drops, even when receiving their prescribed doses. This unpredictability makes diabetes management extremely difficult and increases risks of diabetic emergencies.
The administration of expired insulin compounds these risks by providing residents with medication of unknown potency. Expired insulin may have reduced effectiveness, meaning residents receive inadequate glucose control despite believing they're receiving proper treatment. This can lead to prolonged hyperglycemia, increasing risks of diabetic complications including kidney damage, cardiovascular problems, and infections.
Facility Policies and Industry Standards
Sherman Village HCC maintained written policies addressing proper medication administration that staff failed to follow. The facility's insulin administration policy specifically required site rotation "preferably within the same general area (abdomen, thigh, upper arm)" and mandated checking expiration dates when using multi-dose vials.
The facility's medication error policy defined violations as "preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards." This definition clearly encompassed the documented violations.
Industry standards for insulin administration emphasize injection site rotation as fundamental to safe diabetic care. The American Diabetes Association and manufacturer guidelines consistently recommend rotating sites within body regions to prevent tissue changes that compromise treatment effectiveness.
Staff Knowledge and Training Gaps
Interview responses revealed that nursing staff understood proper medication administration principles but failed to implement them consistently. The Director of Nursing demonstrated awareness of requirements, acknowledging that rotation prevents lipodystrophy and that expired medications pose serious risks.
However, multiple licensed nurses participated in the documented errors, suggesting systemic issues with oversight, training reinforcement, or quality assurance processes. The fact that expired insulin remained in use for weeks indicates gaps in medication monitoring and inventory management.
Licensed Vocational Nurses interviewed recognized the seriousness of their errors, with one stating that improper site rotation could cause "skin abnormalities such as lumps in the skin or thickened skin" and another acknowledging that expired insulin creates risks of "high or low blood sugar levels, leading to coma, hospitalization or even death."
Regulatory Response and Corrections
Federal inspectors classified these violations under medication administration regulations, citing the facility for failing to ensure medications were administered according to physician orders and manufacturer specifications. The violations received a "minimal harm or potential for actual harm" designation, though the documented risks clearly posed serious threats to resident safety.
The facility's Director of Nursing committed to contacting physicians for corrected medication orders and replacing expired insulin supplies. However, the inspection revealed that these fundamental medication safety practices should have been routine operations rather than corrections implemented only after federal oversight.
The violations demonstrate the critical importance of consistent medication administration oversight in long-term care facilities, where residents depend entirely on staff competency for their health and safety. Proper insulin management is particularly crucial for diabetic residents, who face serious health consequences when blood sugar control becomes compromised.
For families with loved ones receiving diabetes care in nursing facilities, these findings highlight the importance of asking specific questions about injection site rotation, medication storage protocols, and staff training in diabetes management. Residents receiving multiple daily medications require particularly careful monitoring to ensure each drug is administered correctly according to its specific requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Village Hcc from 2024-09-06 including all violations, facility responses, and corrective action plans.
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