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F0759
D

Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration

Leesville, Louisiana Survey Completed on 09-04-2025

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 maintain a medication error rate below 5%, as evidenced by direct observation of medication administration. During 29 observed medication administration opportunities, an LPN was seen crushing and administering Pantoprazole DR 40mg tablet and Potassium Chloride ER 10meQ tablet, as well as opening a Tolterodine ER 4mg capsule and providing its contents orally to a resident. The LPN confirmed these actions during an interview. The facility's contract pharmacist verified that these extended-release (ER) and delayed-release (DR) medications should not have been crushed or opened, and stated that no documentation existed to support altering these medications in this manner. This practice had the potential to affect all 145 residents receiving medications in the facility.

See complete original report
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