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F0658
E

Failure to Follow Professional Standards During Medication Administration

Riverside, California Survey Completed on 05-02-2025

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 ensure professional standards of practice were followed during medication administration for three residents. In one instance, a nurse left an open packet of Lidocaine Patch 5% labeled for one resident on a shelf next to another resident, making it readily accessible and not secured in the medication cart or discarded. The nurse confirmed the medication was not handled according to policy, and the Director of Nursing (DON) stated that medications should not be left unattended in the presence of another resident. The facility's policy requires that medications ordered for a particular resident may not be administered to another resident and must be administered safely and as prescribed. In another case, a nurse administered medication to a resident without verifying the resident's identity. The resident was cognitively intact and had a history of a right wrist and hand fracture, bradycardia, and difficulty walking. The nurse acknowledged not following the facility's process of confirming the resident's name and date of birth or checking the identification wristband before administering medication. The DON and another nurse both confirmed that the expectation is to verify resident identity before medication administration, as outlined in the facility's policy. Additionally, a nurse did not provide privacy to a resident during medication administration. The resident, who was cognitively intact and had a history of a left femur fracture, diabetes, and hypertension, was not afforded privacy such as pulling a curtain or closing the door during the process. The nurse admitted to not providing privacy and stated that it is the resident's right. The DON reiterated that staff should promote, maintain, and protect resident privacy during treatment procedures, as required by the facility's dignity policy.

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