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F0755
D

Incomplete Administration of Medications via G-Tube

Montebello, California Survey Completed on 04-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a licensed vocational nurse (LVN) failed to fully administer two prescribed medications, Acetazolamide and Oyster Shell Calcium/Vitamin D, to a resident with severe cognitive impairment and total dependence for daily activities, who was receiving medications via a gastrostomy tube. The LVN prepared the medications by crushing and mixing them in water, but did not ensure the entire dose was delivered, leaving approximately 70% of the Oyster Shell Calcium and 50% of the Acetazolamide in the medication cup. This resulted in the resident not receiving the full prescribed doses as ordered by the physician. The resident involved had a history of urinary tract infection and congestive heart failure, and was dependent on a feeding tube for medication administration. The facility's policy and procedure required that medications be administered in accordance with prescriber's orders and tailored to resident needs. Both the LVN and the Director of Nursing confirmed that the medications were not completely administered, which was not in accordance with the facility's policy.

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