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F0726
D

Failure to Ensure Staff Competency in Medication Administration and Resident Privacy

Los Angeles, California Survey Completed on 05-16-2025

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

A Licensed Vocational Nurse (LVN) failed to demonstrate the necessary skills and knowledge to safely prepare and administer medications for a resident with schizophrenia, hypertension, and dysphagia. The LVN crushed all of the resident's morning medications and mixed them together in applesauce without a physician's order to do so. The LVN was unable to identify the medications being administered, did not verify the resident's identity, and admitted to not reviewing the physician's orders prior to administration. The Registered Nurse Supervisor confirmed that there was no order to crush the medications and that the LVN did not follow proper procedures for medication administration, including not crushing medications together and not ensuring the resident was present during preparation. A Certified Nursing Assistant (CNA) failed to provide care with dignity and respect to a resident with dementia, hypertension, and dysphagia who was dependent for activities of daily living. The CNA was observed changing the resident's incontinence diaper in a shared room with the privacy curtain open, leaving the resident's private areas exposed. The CNA was unable to explain the importance of maintaining privacy during personal care and responded inappropriately when questioned about the procedure. Another nurse present confirmed that privacy should have been maintained during the care activity. The facility's policies and procedures require that nursing staff participate in competency-based training and demonstrate skills necessary to meet residents' needs, including medication management and respecting resident rights. The observed actions of the LVN and CNA were not consistent with these requirements, as both failed to follow established protocols for safe medication administration and resident privacy.

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