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F0755
D

Failure to Provide Scheduled Invega Injections Due to Medication Unavailability

Salt Lake City, Utah Survey Completed on 06-19-2025

Penalty

Fine: $13,000
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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 with multiple psychiatric and medical diagnoses, including severe dementia with agitation, paranoid schizophrenia, and schizoaffective disorder, did not receive scheduled doses of Invega intramuscular injections as ordered. On several occasions, the medication was not available at the facility when it was due to be administered. Specifically, on one occasion, the injection was not given because it had not arrived at the facility, and on another, the medication was unavailable due to issues with insurance coverage. Documentation in the Medication Administration Record (MAR) and nurse notes confirmed these missed doses, with one instance lacking a documented reason for non-administration. The resident's medication orders for Invega were adjusted multiple times, including changes in dosage and administration schedule, in an effort to accommodate insurance requirements. Despite these adjustments, there were repeated failures to provide the medication as scheduled, resulting in missed doses. The facility's process for ordering and ensuring the timely availability of the medication was insufficient, as evidenced by the need to call the pharmacy to reorder the medication and the subsequent delay in administration.

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