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F0755
E

Failure to Administer Prescribed Antipsychotic Medication Due to Delayed Delivery and Authorization

Riverside, California Survey Completed on 04-11-2025

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 a resident diagnosed with dementia with psychotic disturbances and impulse disorder. The resident was prescribed Rexulti 2 mg daily for unspecified psychosis manifested by delusions. According to the Medication Administration Record (MAR), the medication was not administered on twelve separate occasions over a period of nearly one month. Progress notes indicated that the missed doses were due to delayed prescription delivery, pending insurance authorization, and lack of medication availability. There was also a lack of follow-up with the pharmacy to resolve these issues in a timely manner. Interviews with the Director of Nursing (DON) and the facility pharmacist confirmed that the medication should have been administered as ordered and that the missed doses were not appropriately addressed. The facility's policy required medications to be administered in accordance with prescribed orders and within required time frames, but this was not followed. The failure to provide the prescribed medication as ordered resulted in interrupted care for the resident.

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