LOS ANGELES, CA - Federal inspectors documented serious medication safety failures at Western Convalescent Hospital that contributed to resident injuries.
Critical Medication Administration Failures
A March 2025 inspection revealed Western Convalescent Hospital administered amlodipine, a blood pressure medication, outside prescribed safety parameters 81 times between April 2024 and January 2025. The medication was given to Resident 83 when her systolic blood pressure was below 120, despite specific physician orders to hold the medication under these conditions.
This pattern of medication errors directly contributed to two documented falls resulting in injuries. On April 10, 2024, the resident was found on the floor with a cut on her forehead and wrist pain. On June 20, 2024, another fall resulted in right-side facial swelling. In both instances, the blood pressure medication had been administered outside the prescribed safety parameters on or immediately before the fall dates.
Blood Pressure Safety Parameters Ignored
Amlodipine requires careful monitoring because administering it when blood pressure is already low can cause dangerous drops in blood pressure, leading to dizziness and increased fall risk. The medication order specifically stated to hold doses when systolic blood pressure readings were below 120.
However, inspection records showed nursing staff consistently failed to follow these critical safety guidelines. The facility's consultant pharmacist had previously recommended in December 2024 to "please consistently acknowledge SBP hold parameter," indicating ongoing awareness of the problem.
Blood pressure medications work by reducing the force of blood circulation. When given to patients whose blood pressure is already low, these medications can cause orthostatic hypotension - a condition where blood pressure drops significantly when changing positions. This creates immediate fall risks, particularly dangerous for elderly residents who may already have balance or mobility issues.
Orthostatic Blood Pressure Monitoring Failures
Inspectors also identified significant gaps in nursing staff competency regarding orthostatic blood pressure monitoring. Two Licensed Vocational Nurses demonstrated inadequate understanding of proper procedures for checking orthostatic hypotension.
One nurse incorrectly stated that if a lying blood pressure reading didn't show hypotension, a sitting measurement wasn't necessary. Another nurse claimed the two required readings could be taken at any convenient time during the shift, rather than following the proper protocol of waiting approximately five minutes between position changes.
Proper orthostatic blood pressure monitoring requires taking an initial reading with the patient lying down, having them sit up, waiting about five minutes for circulation to adjust, then taking a second reading. A drop of 20 mmHg in systolic pressure or 10 mmHg in diastolic pressure indicates positive orthostatic hypotension, requiring physician notification and potential medication adjustments.
Additional Medication Safety Concerns
The inspection revealed a broader pattern of medication administration problems beyond the blood pressure medication errors. Nursing staff administered incorrect medication strengths and formulations to two residents during observed medication passes, contributing to an overall medication error rate of 6.06% - above the acceptable 5% threshold.
In one case, a resident received cranberry supplement tablets that were 450 mg instead of the prescribed 425 mg. Another resident received tablet-form multivitamins instead of the prescribed liquid formulation. These errors occurred despite facility policies requiring staff to read medication labels before administration and follow physician orders precisely.
The medication administration failures extended to monitoring requirements as well. For one resident taking lorazepam for anxiety, nursing staff failed to document the specific behaviors the medication was intended to treat, making it impossible to assess whether the medication was effective.
Laboratory Testing and Care Coordination Issues
Inspection findings also highlighted problems with laboratory test coordination. One resident was prescribed a thyroid panel to monitor potential side effects from psychiatric medication but received different thyroid-related tests instead. This type of error can prevent physicians from properly monitoring medication safety and effectiveness.
The resident was taking Seroquel, which can affect thyroid function, making proper monitoring essential for preventing complications. When incorrect laboratory tests are performed, physicians lack the necessary information to make informed decisions about continuing or adjusting medications.
Dietary and Infection Control Violations
Beyond medication safety, inspectors documented problems with meal service for residents requiring modified food textures. Eighteen residents on soft and bite-size diets received whole bread rolls instead of properly sized food pieces, creating choking risks.
The facility's menu system hadn't been updated to reflect current dietary standards, creating confusion between physician diet orders and kitchen preparation guidelines. Staff acknowledged having recipes for mechanical soft diets but not for the newer soft and bite-size diet specifications required by physician orders.
Food safety issues included a dirty, worn can opener blade with brown residue in the kitchen preparation area and improper storage of opened food items in resident rooms that required refrigeration.
Staffing and Care Quality Impact
The inspection revealed chronic understaffing of Restorative Nursing Aides (RNAs), who provide essential rehabilitation services to 81 residents. Multiple days showed zero RNA staff coverage, with remaining RNAs frequently reassigned to general nursing duties due to overall staffing shortages.
This staffing pattern meant residents missed ordered rehabilitation treatments designed to maintain mobility, prevent contractures, and preserve activities of daily living. Without consistent RNA services, residents faced increased risks of functional decline and reduced quality of life.
Regulatory Response and Resident Safety
The inspection resulted in multiple citation tags for medication administration, nursing competency, laboratory services, dietary services, and infection control. While classified as causing "minimal harm or potential for actual harm," the documented pattern of medication errors that contributed to actual resident injuries demonstrates serious safety concerns.
The facility's own policies required sufficient nursing staff with appropriate competencies and strict adherence to physician medication orders. The inspection findings show systematic failures to meet these basic safety requirements, particularly regarding blood pressure medication management where proper administration protocols are critical for preventing falls and injuries.
These violations highlight the importance of proper medication administration training, consistent adherence to safety parameters, and adequate staffing to ensure quality resident care. When safety protocols fail, vulnerable nursing home residents face increased risks of preventable injuries and medical complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Western Conv. Hospital from 2025-03-21 including all violations, facility responses, and corrective action plans.
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