NORTH HOLLYWOOD, CA - Federal inspectors documented medication safety violations at Sherman Village HCC involving improper management of psychotropic drugs for a hospice patient.
Medication Safety Protocol Failures
During a September 2024 inspection, surveyors identified multiple violations in the facility's handling of psychotropic medications for Resident 24, who was enrolled in hospice care with diagnoses including Type 2 diabetes, dementia, depression, and psychosis.
The facility failed to establish required time limits for lorazepam, an anxiety medication prescribed on an as-needed basis. Federal regulations require PRN psychotropic medications to include specific durations, typically limited to 14 days unless clinical justification is documented for extensions.
Lorazepam Safety Concerns
Resident 24 was prescribed lorazepam 0.5 mg every 6 hours as needed for anxiety and restlessness, beginning in June 2024. However, facility records contained no stop date or duration specification for this order, violating both federal requirements and the facility's own policies.
Lorazepam belongs to the benzodiazepine class of medications, which can cause significant adverse effects when used without proper monitoring. These medications can lead to drowsiness, dizziness, confusion, and increased fall risk - particularly concerning for elderly residents with dementia.
Antidepressant Dose Reduction Requirements
The facility also failed to attempt required dose reductions for Resident 24's antidepressant medication. The resident had been taking escitalopram (Lexapro) 5 mg daily since March 2023 for depression, but showed no documented depressive behaviors between January and June 2024.
Federal guidelines mandate gradual dose reduction attempts for psychotropic medications during the first year of admission in two separate quarters, with at least annual attempts thereafter unless clinically contraindicated. The facility's consultant pharmacist specifically recommended considering a dose reduction in July 2024.
Clinical Documentation Deficiencies
When the consultant pharmacist noted the prolonged use of escitalopram and recommended dose reduction consideration, the attending physician disagreed but provided only a handwritten note stating the medication was part of "end of life comfort measures." This response lacked proper clinical rationale and contained no physician signature.
The facility's Director of Nursing acknowledged during the inspection that proper assessment of absent depressive behaviors should have prompted either a gradual dose reduction attempt or documented clinical justification for continuing the current dosage.
Medication Error Rate Violations
Inspectors also identified a separate medication safety concern: the facility's medication error rate exceeded federal limits. Out of 31 medication administration opportunities observed, surveyors documented 2 errors, resulting in a 6.45% error rate - above the 5% federal threshold.
The specific errors included: - One resident receiving ascorbic acid that was not prescribed - Another resident not receiving prescribed multivitamin with iron
Federal Requirements and Best Practices
Psychotropic medications require heightened oversight in nursing homes due to their potential for serious side effects and the vulnerability of elderly residents. Federal regulations establish specific requirements for their use, including:
Time-limited PRN orders with clear clinical justification for extensions beyond 14 days Regular assessment of continued need through gradual dose reduction attempts Comprehensive documentation of clinical rationale when dose reductions are contraindicated Ongoing monitoring for adverse effects and medication appropriateness
These requirements aim to prevent unnecessary exposure to medications that can cause drowsiness, confusion, movement disorders, and other serious complications that significantly impact quality of life.
Hospice Care Coordination Challenges
The violations occurred despite Resident 24's enrollment in hospice care, which focuses on comfort and quality of life during end-of-life care. The facility's own hospice policy emphasizes coordinated care plans that maintain residents' highest practicable well-being while working with hospice providers.
However, the inspection findings suggest coordination gaps that allowed inappropriate medication practices to continue without proper clinical oversight or documentation.
Facility Response and Corrective Measures
The Director of Nursing acknowledged the violations during the inspection, recognizing that unnecessary psychotropic medication use can cause significant adverse effects including tardive dyskinesia (uncontrolled facial movements), akathisia (inability to remain still), and general decline in quality of life.
The nursing director stated plans to review all hospice orders and coordinate care to ensure proper implementation of resident care plans while maintaining optimal well-being without adverse medication effects.
Industry Standards for Psychotropic Use
Nursing home regulations require facilities to minimize unnecessary drug use while ensuring residents receive appropriate treatment. For psychotropic medications specifically, this means:
Regular evaluation of continued clinical need Systematic attempts to reduce doses when appropriate Clear documentation of medical justification when reductions are not attempted Time-limited PRN orders with specific clinical indications Coordination with prescribing physicians and consulting pharmacists
The goal is ensuring residents receive optimal treatment that addresses their conditions without exposing them to unnecessary risks from prolonged or inappropriate medication use.
Medical Monitoring Requirements
Proper psychotropic medication management requires ongoing assessment of both therapeutic benefit and potential adverse effects. For elderly residents with multiple conditions, this monitoring becomes particularly critical as medication interactions and age-related changes in drug metabolism can increase risks.
Federal guidelines recognize that some residents may require continued psychotropic treatment, but mandate systematic evaluation to ensure the benefits outweigh potential harms. When dose reductions are clinically contraindicated, physicians must document specific rationales explaining why reduction attempts would likely impair function or worsen symptoms.
The violations at Sherman Village HCC represent failures in this systematic approach, potentially exposing residents to unnecessary medication risks without adequate clinical justification or monitoring protocols.
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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