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F0755
E

Failure to Administer Medications Within Prescribed Timeframe

Pasadena, California Survey Completed on 04-16-2025

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

The facility failed to provide pharmaceutical services to meet the needs of three residents when a Licensed Vocational Nurse (LVN) did not administer scheduled medications within 60 minutes of the prescribed 9 AM time. This was observed for three residents with complex medical histories, including Huntington's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, and schizophrenia. The facility's policy required medications to be administered within 60 minutes of the scheduled time, except for those ordered before, with, or after meals. For one resident with Huntington's disease, dementia, and anxiety disorder, the medication administration was observed at 10:02 AM, over an hour past the scheduled time. The LVN prepared and administered several medications, including Buspirone, Cholecalciferol, Tetrabenazine, Zoloft, and Zyprexa, after the scheduled window. Another resident with diabetes, autistic disorder, and dementia had multiple 9 AM medications, such as Aspirin, Cholecalciferol, Finasteride, Gabapentin, Glipizide, and others, not administered by 10:30 AM. The LVN was unable to locate one of the medications (chewable aspirin) during the medication pass. A third resident with COPD, schizophrenia, and major depressive disorder also did not receive their 9 AM medications by 10:18 AM, as indicated by blank documentation on the medication administration record. The LVN reported technical issues with the electronic medication administration record (MAR) as the reason for the delay. Interviews with nursing staff and the Director of Nursing confirmed that medications were administered late and emphasized the importance of timely administration as per physician orders and facility policy.

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