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F0755
D

Late Medication Administration by LVN

Torrance, California Survey Completed on 09-03-2025

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) administered ten medications to a resident three hours after the scheduled 9 a.m. administration time, with the medications being given at 12:08 p.m. The medications included treatments for diabetes, hypertension, stroke prophylaxis, and supplements, all of which were ordered to be administered at specific times according to the resident's physician orders and care plans. The LVN stated the delay was due to being occupied with other residents' needs, including addressing family concerns and managing a gastrostomy tube for another resident. The resident involved had a medical history of hemiplegia, hemiparesis, diabetes, hypertension, hyperlipidemia, congestive heart failure, and a history of cardiac arrest and stroke. The resident was cognitively intact but dependent on staff for activities of daily living. The care plans for this resident specifically required timely administration of medications to manage risks related to blood pressure, blood sugar, and anticoagulant therapy, with interventions including administering medications as ordered and monitoring for side effects. Facility policy and the LVN's job description both required medications to be administered within one hour of the prescribed time unless otherwise specified. The Director of Nursing confirmed that late administration should be documented, and the physician and family should be notified. However, in this instance, the medications were administered late without adherence to these protocols, resulting in a failure to meet the pharmaceutical service needs of the resident as required.

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