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F0684
D

Medication Order Lacked Indication and Was Inappropriately Modified by LVN

San Jose, California Survey Completed on 07-22-2025

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 deficiency occurred when a resident was prescribed Ivermectin without an indication for use identified in the physician's order. The order, dated 6/24/25, specified the dosage and duration but did not state the clinical reason for prescribing the medication. Upon review, the Medication Administration Record (MAR) reflected the medication was to be given for a 'parasite infection,' but this indication was not present in the original order. During interviews, the Licensed Vocational Nurse (LVN) who processed the order admitted to not knowing the intended use of Ivermectin and stated she added 'for parasite infection' to the MAR after searching for information online, without confirming a diagnosis or indication with the prescriber. Further review and interviews with the Assistant Director of Nursing (ADON) confirmed that the facility's process requires clarification of any medication order lacking an indication, and that assigning a diagnosis is outside the LVN's scope of practice. The facility's policy mandates that medication orders must include the clinical condition or symptoms for which the medication is prescribed. The failure to clarify the order and the unauthorized addition of an indication by the LVN resulted in care and treatment not being provided in accordance with professional standards of practice.

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