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F0658
E

Failure to Follow Medication Administration Standards Due to Pre-Pouring by LVN

San Pablo, California Survey Completed on 06-26-2025

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 licensed vocational nurse (LVN) failed to adhere to professional standards during medication administration for four residents. The LVN was observed carrying a medication tray containing multiple pre-poured medication cups labeled with room numbers, rather than preparing medications immediately before administration as required by facility policy. The LVN administered medications to residents after preparing them in advance, a practice known as pre-pouring, which is not permitted according to the facility's guidelines. The LVN stated during interviews that she routinely prepared medications ahead of time to expedite her medication pass and was unaware of the facility's policy prohibiting pre-pouring. She also indicated that she memorized the medications for each resident and did not perceive any risk of medication errors with this method. The LVN further explained that if medication cups were mixed up, she would discard the medications and start over, but did not acknowledge the potential for error inherent in this process. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be prepared and administered to one resident at a time, with verification of the resident's identity prior to administration. The DON emphasized that pre-pouring medications is not allowed due to the risk of medication errors and infection control breaches. The facility's written policy also specifies that medications are to be administered at the time they are prepared and not pre-poured, and that documentation should occur immediately after administration.

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