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F0658
E

Failure to Follow PPE Protocols and Physician Orders

San Jose, California Survey Completed on 06-27-2025

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

Two Licensed Vocational Nurses (LVNs) failed to wear proper Personal Protective Equipment (PPE), specifically gloves, while handling a medication labeled as a hazardous drug (Divalproex Sodium) for two residents. Both LVNs acknowledged that the medication packaging was marked with a hazardous drug label and admitted they should have worn gloves during administration. The Director of Nursing and Consultant Pharmacist confirmed that gloves are required when handling such medications, and the facility's policy mandates the use of appropriate PPE to minimize exposure to hazardous drugs. Additionally, a resident with a primary diagnosis of unspecified paraplegia had a physician's order for weekly weight monitoring every Saturday at 9:00 a.m. However, the resident's weight was not monitored as ordered, with the last recorded weight taken over a month prior to the review. The nursing supervisor and Director of Nursing both verified that the physician's order for weekly weight checks was not followed, and the facility's policy requires all physician orders to be carried out accurately and promptly.

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