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F0684
D

Pre-pulled Medications Found on Dementia Unit

Owensboro, Kentucky 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

Facility staff failed to provide treatment and care in accordance with professional standards of practice, as evidenced by the pre-pulling of medications for three residents on the Dementia unit. During an observation, a Medication Tech was found with three medication cups, each containing medications that had been prepared in advance and labeled with the residents' names. These cups were stored in the top drawer of the medication cart, contrary to the facility's Medication Administration policy, which requires medications to be administered by licensed or authorized staff as ordered and in accordance with professional standards. The Medication Tech acknowledged during an interview that she was aware pre-pulling medications was not permitted and recognized the associated risks, especially given the vulnerability of residents on the Dementia unit. Both the DON and the Administrator confirmed that this practice was not in line with facility policy and described it as a significant safety risk due to the potential for medication errors. The facility's policies on medication administration and residents' rights were reviewed and found to require adherence to professional standards and proper care for residents.

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