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F0658
E

Failure to Administer Medications According to Professional Standards

Richmond, Virginia Survey Completed on 04-28-2025

Penalty

Fine: $93,440
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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 were administered according to professional standards for one resident with multiple diagnoses, including Parkinson's disease, heart failure, and dementia with depression and anxiety. The resident was known to refuse medications and other care, as documented in the care plan, which included interventions such as administering medications as ordered and assigning familiar staff. During an interview, an LPN stated that the resident had not received any pain medication following a dental procedure, attributing this to the resident's tendency to refuse medications and aggravate nurses. The LPN also described a practice of not preparing medications in advance for this resident, instead asking if the resident would take medications before removing them from the cart. On the day in question, the resident initially refused all medications during the morning pass but later accepted pain medication for significant mouth pain, which was then administered. The LPN's statements indicated that the process for offering and administering medications deviated from professional standards, which require verification and preparation of medications prior to administration, as well as confirmation of medication rights at multiple steps. The facility's leadership did not provide comments or express concerns when interviewed about these findings.

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