SEO_DESCRIPTION: Sherman Oaks Health & Rehab cited for failing to monitor life-threatening bleeding risks in residents taking blood thinners, plus psychotropic medication violations.
OG_TITLE: Sherman Oaks Nursing Home Failed to Monitor Life-Threatening Bleeding in Blood Thinner Patients
OG_DESCRIPTION: Federal inspectors found Sherman Oaks Health & Rehab failed to monitor residents for dangerous bleeding from blood thinners, administered unauthorized psychotropic drugs, and had a 12.5% medication error rate during March 2025 inspection.
FB_POST: CA nursing home failed to monitor residents for life-threatening bleeding from blood thinners, feds find
ARTICLE:
SHERMAN OAKS, CA - Federal inspectors documented serious medication safety violations at Sherman Oaks Health & Rehab, including failures to monitor residents for life-threatening bleeding from blood thinners and unauthorized administration of psychotropic medications.
Critical Blood Thinner Monitoring Failures
The March 2025 inspection revealed the facility failed to monitor multiple residents for signs of bleeding while taking anticoagulant medications. Resident 42 was prescribed both Eliquis and clopidogrel for atrial fibrillation but received no documented monitoring for bleeding or bruising despite care plan requirements.
The resident's care plan specifically identified the risk of "bleeding and bruising due to anticoagulant therapy" and required daily assessment for "signs and symptoms of bleeding." However, the medication administration record contained no documentation of this critical monitoring.
Resident 40 faced similar risks while taking apixaban for deep vein thrombosis prevention. Despite being on this high-risk anticoagulant medication for over one year, facility records showed no physician orders for adverse effect monitoring.
Blood thinners prevent dangerous clots but significantly increase bleeding risk. Without proper monitoring, residents can experience internal bleeding that goes undetected, potentially leading to hemorrhage, hospitalization, or death. The medications work by interfering with the body's natural clotting mechanisms, making even minor injuries potentially serious.
Director Acknowledges Safety Failures
During interviews with federal inspectors, the facility's Director of Nursing acknowledged the monitoring failures. "It was important to check for lipid levels for residents using atorvastatin to know if the medications was effective, and not causing more harm than benefit," the director stated.
Regarding blood thinner monitoring, the director confirmed this was "considered standard of practice" and that without adequate monitoring, "these medications have the potential to be used unnecessarily causing more harm than benefit."
Licensed Vocational Nurse 1 told inspectors that Resident 79 should be monitored for lipid levels at least once to ensure atorvastatin effectiveness and determine if dosage changes were necessary.
Psychotropic Medication Violations
The facility also failed to properly manage psychotropic medications affecting five residents. Resident 95 received lorazepam beyond the authorized 30-day period without physician reauthorization, violating federal requirements that limit PRN psychotropic medications to 14 days.
The facility administered four doses of lorazepam to Resident 95 after March 6, 2025 - the 30th day from the original order date - constituting unauthorized medication administration. Lorazepam carries significant side effects including drowsiness, confusion, and fall risks, particularly dangerous for residents with dementia.
Resident 8 received two psychotropic medications without proper informed consent documentation. Despite facility policy requiring signed consent forms before psychotropic administration, both sertraline and divalproex sodium consent forms remained blank for signatures from the resident's representative and prescribing physician.
Lack of Specific Target Behaviors
The inspection revealed systemic problems with psychotropic medication orders lacking specific, measurable target behaviors. Resident 79's divalproex was ordered for "mood fluctuations" - terminology inspectors found too vague for effective monitoring.
Resident 89 was prescribed fluoxetine for "persistent feelings of hopelessness/helplessness," which staff identified as an emotion rather than a measurable behavior. Without specific behavioral targets, different nurses interpret symptoms inconsistently, preventing accurate assessment of medication effectiveness.
The facility's consultant pharmacist confirmed these medications require specific behavioral monitoring to determine effectiveness and avoid unnecessary psychotropic drug use that could cause "more harm than benefit."
Dangerous Medication Error Rate
Medication administration observations revealed a 12.5% error rate - well above the federal 5% maximum. Four medication errors occurred during 32 administration opportunities, affecting residents receiving critical cardiovascular and diabetes medications.
Resident 21 experienced three separate medication errors in one administration session: receiving carvedilol 2 hours and 12 minutes late, getting the wrong form of multivitamin, and missing prescribed polyethylene glycol entirely. Carvedilol requires administration with food to prevent stomach irritation and ensure proper absorption.
Resident 77 received carvedilol nearly 2 hours late, outside the facility's one-hour administration window. Both residents were prescribed carvedilol for hypertension, requiring precise timing for optimal blood pressure control.
Insulin Site Rotation Failures
Multiple residents receiving insulin experienced medication errors due to improper injection site rotation. Resident 17 received insulin injections repeatedly in the same abdominal quadrant over multiple days, violating physician orders requiring site rotation.
Proper insulin injection site rotation prevents lipodystrophy - abnormal fat distribution creating skin pits or thickened areas. The manufacturer guidelines specifically warn against injecting where skin "has pits, is thickened, or has lumps" as this affects insulin absorption and can cause localized tissue damage.
Resident 48 experienced similar site rotation failures with both insulin glargine and insulin lispro injections. Federal standards require rotation within body areas to prevent tissue damage and ensure consistent medication absorption for blood sugar control.
Medical Standards and Requirements
Anticoagulant monitoring represents a fundamental safety requirement in nursing homes. The medications' therapeutic window - the range between ineffective dosing and dangerous bleeding - requires vigilant observation for early bleeding signs including unusual bruising, changes in mental status, or unexplained weakness.
Psychotropic medication management involves strict federal requirements including informed consent, specific behavioral targets, limited PRN duration, and regular effectiveness evaluation. These protections prevent unnecessary chemical restraint and minimize adverse effects in vulnerable populations.
Insulin administration standards mandate injection site rotation to prevent tissue damage that can affect medication absorption and blood sugar control. Consistent sites can develop scar tissue, reducing insulin effectiveness and creating unpredictable blood sugar fluctuations.
Facility Response and Corrections
The facility acknowledged all violations during the inspection process. The Director of Nursing committed to immediately implementing monitoring protocols for bleeding with blood thinner use and obtaining required lipid panel testing for residents on atorvastatin.
For psychotropic medication violations, the facility agreed to implement proper behavioral monitoring, ensure informed consent procedures, and establish appropriate PRN medication duration limits. Staff received additional training on medication administration timing requirements and injection site rotation protocols.
The consultant pharmacist acknowledged failing to identify monitoring deficiencies during monthly drug regimen reviews for December 2024, January 2025, and February 2025, despite these being "standard of practice" requirements.
Sherman Oaks Health & Rehab must develop comprehensive corrective action plans addressing each violation area to prevent future medication safety failures and protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Oaks Health & Rehab from 2025-03-14 including all violations, facility responses, and corrective action plans.
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