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F0658
E

Late Administration of Scheduled Medications

La Crescenta, California Survey Completed on 04-25-2025

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 resident with multiple complex medical conditions, including multiple sclerosis, hypertension, atrial fibrillation, prostate cancer, and anxiety disorder, did not receive his scheduled 9 AM medications within the facility's required timeframe. The resident was alert, oriented, and had intact cognitive skills, with care plans in place for hypertension, constipation, and cardiac function deficit, all of which included the intervention to administer medications as ordered. Despite these care plans, the resident's 9 AM medications were administered at 11:11 AM, more than two hours late. Observation and interviews revealed that the resident was visibly angry and frustrated due to the delay. The LVN responsible for administering the medications acknowledged the delay, stating she was busy with other residents and recognized the importance of timely medication administration, especially for managing the resident's depression, muscle spasms, and hypertension. The medication administration record confirmed that 20 different medications, including those for blood pressure and atrial fibrillation, were given late. Further interviews with nursing staff and the DON confirmed that the facility's policy requires medications to be administered within 60 minutes of the scheduled time to optimize drug therapy and ensure resident well-being. The late administration of medications was acknowledged as a deviation from both professional standards of practice and the facility's own policies, resulting in the resident's anger and frustration and the potential for his blood pressure to be affected.

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