LOS ANGELES, CA - Federal inspectors found several significant violations at Westwood Post Acute Care during an April 2025 inspection, including unauthorized access to medical records and medication management failures that resulted in a resident being hospitalized for severe hypoglycemia.
Unauthorized Access to Medical Records Raises Privacy Concerns
The most serious violation involved a breach of federal privacy laws when an unidentified liaison gained access to a resident's medical records without proper authorization. The incident involved Resident 48, who was readmitted to the facility with complete paraplegia and essential hypertension and was receiving hospice care.
The liaison, who identified herself as an independent placement specialist with no medical background or facility employment, obtained the resident's medical records from the hospice company. Despite never meeting with the resident or family members, she arranged for the resident's discharge to home hospice care based solely on her interpretation that the resident was "unhappy with the facility."
During the investigation, the resident's primary care physician stated he never authorized the liaison's involvement and was unaware of her role in the discharge process. The physician emphasized he would never discharge a resident home without ensuring adequate caregiver support was in place.
Federal privacy laws require strict controls over who can access patient medical information. Under the Health Insurance Portability and Accountability Act (HIPAA), facilities must limit access to protected health information to only what is minimally necessary for the intended purpose. When individuals outside the direct care team need access to medical records, specific authorization and justification are required.
The facility's own policy states that entire medical records should only be disclosed when "specifically and reasonably necessary to accomplish the purpose," and requests for complete records must be justified in writing. This violation represents a significant breach of patient privacy rights and could expose sensitive medical information to unauthorized individuals.
Critical Diabetes Management Failures Lead to Hospitalization
A second major violation involved dangerous medication management errors for Resident 56, a newly admitted patient with Type 1 diabetes. The failures in diabetes care protocols resulted in the resident experiencing severe hypoglycemia with a blood sugar level of 25 mg/dL, requiring emergency hospitalization.
The sequence of errors began when nursing staff administered pre-meal insulin without checking blood sugar levels on multiple occasions. On March 20, 2025, the Licensed Vocational Nurse (LVN) gave insulin at 11:30 AM and 4:30 PM without first measuring the resident's blood glucose, contrary to standard diabetes management protocols.
More critically, when the resident's blood sugar spiked to 541 mg/dL at 4:30 PM - well above the facility's threshold for physician notification - the nurse failed to administer the required insulin dose according to physician orders. The resident received long-acting insulin that morning despite eating virtually nothing for breakfast, creating conditions for dangerous blood sugar fluctuations.
Six hours later, at 10:30 PM, the same nurse administered insulin based on the outdated 4:30 PM blood sugar reading without rechecking current levels or following up with additional monitoring. This practice violated multiple safety protocols and contributed to the resident's unstable glucose control.
Proper diabetes management requires frequent blood sugar monitoring and careful coordination between food intake and insulin administration. For Type 1 diabetics, the balance is particularly critical because they produce no natural insulin. Missing blood sugar checks or administering insulin without current readings can lead to life-threatening complications including diabetic coma, seizures, or death.
The resident's family member expressed trauma over the incident, questioning why blood sugar wasn't checked for over 11 hours and why nursing staff didn't monitor the resident more closely after high readings. The family noted their loved one had managed Type 1 diabetes for decades, making the facility's management failures particularly concerning.
Medical Context: Understanding the Risks
These violations highlight critical safety issues in nursing home care. Privacy breaches can lead to inappropriate discharge decisions when unqualified individuals make medical determinations without proper clinical oversight. Residents with complex medical conditions like paraplegia and terminal diagnoses require coordinated care teams with appropriate medical supervision.
Diabetes management errors pose immediate life-threatening risks. Hypoglycemia can cause confusion, loss of consciousness, seizures, and death within hours if untreated. Severe episodes often require emergency intervention including glucagon injections and hospital transport. The resident in this case required multiple emergency medications and was transferred by ambulance to the hospital emergency department.
Type 1 diabetes requires precise insulin management because patients cannot produce their own insulin. Blood sugar levels must be checked before each insulin dose to ensure appropriate dosing. Missing these checks or relying on outdated readings can cause dangerous swings between extremely high and low blood sugar levels.
Care Planning and Maintenance Issues
The inspection also identified failures in comprehensive care planning for Resident 55, who experienced multiple gastrostomy tube dislodgements requiring hospitalizations. The facility failed to develop proper care plans addressing these recurring issues or conduct required interdisciplinary team meetings to prevent future incidents.
Care plans serve as roadmaps for consistent care delivery across all staff members. Without proper planning, residents may receive inconsistent care that fails to address their specific medical needs and risk factors. For residents with feeding tubes, dislodgement prevention requires specialized protocols to avoid malnutrition and frequent hospitalizations.
Additional maintenance violations affected Resident 64's living environment, including non-functioning hot water, broken blinds, and an unstable television mount. While these issues may seem minor compared to medical violations, they reflect broader maintenance problems that could affect resident safety and quality of life.
Additional Issues Identified
The inspection documented several other concerns including incomplete discharge planning documentation and failure to follow facility policies for maintaining building repairs. The maintenance supervisor acknowledged multiple repair needs but had not addressed them promptly, potentially creating safety hazards for residents.
The facility's own policies require maintaining buildings and equipment in safe, operable condition at all times, and providing residents with a safe, clean, comfortable environment. These standards were not consistently met during the inspection period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Post Acute Care from 2025-04-04 including all violations, facility responses, and corrective action plans.
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