Nursing Home News — Page 1138

## Dangerous Splint Application Errors Inspectors witnessed concerning practices during resident care observations.

The Institute for Safe Medication Practices classifies insulin as a "high alert medication" because errors can cause devastating consequences for residents.

The resident required seven different medications to be crushed and administered through the gastrostomy tube.

These protocols extend beyond standard precautions and require specific protective equipment during high-risk procedures.

The violations affected residents transferred to hospitals between October 2024 and January 2025.

This finding is particularly troubling as it represents a continuation of problems identified in the facility's previous inspection cycle.

LOS ANGELES, CA - Federal inspectors documented serious medication safety failures at Western Convalescent Hospital that contributed to resident injuries.

The resident, who had chronic obstructive pulmonary disease and chronic respiratory failure, had not had a bowel movement for two to three days.

"The wedges should be placed under the bed sheet and not under the mattress," acknowledged an LPN supervisor during the inspection.

**The facility failed to clarify which physician should oversee treatment**, creating potential conflicts in care plans and medication orders.

Multiple residents reported waiting between one to two hours for help with toileting, personal hygiene, and other essential care.

The incident came to light when a passerby noticed someone walking up a hill who appeared to be a facility resident and alerted staff at 4:15 PM.