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F0761
D

Unattended Insulin Syringes and Medications Left in Resident Room

Los Angeles, California Survey Completed on 06-17-2025

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 ensure that medications, specifically insulin syringes and solutions, were not left unattended in a resident's room. On multiple occasions, nursing staff placed insulin syringes and medications on the resident's bed and wheelchair and then left the room, leaving the medications unattended. This was observed both during a surveyor's visit and confirmed through staff interviews. The unattended medications included Novolog and Novolin R insulin solutions, which were prepared for a resident with type 2 diabetes mellitus, chronic kidney disease, and major depressive disorder. The resident was assessed as having intact cognitive skills and the capacity to make decisions. The facility's own policies required that medications be administered at the time they are prepared and not left unattended unless specifically authorized for bedside storage. Despite this, staff admitted to leaving insulin syringes and medications unattended, and one incident resulted in a certified nursing assistant being accidentally poked by a syringe left on the resident's wheelchair. Staff interviews confirmed awareness that medications should not be left unattended, and the facility's policies were not followed in these instances.

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