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F0550
D

Failure to Ensure Privacy During Injectable Medication Administration

Sanford, Florida Survey Completed on 12-10-2025

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 nurse was observed administering an injectable medication, specifically Lantus insulin, to a resident in a common area of the facility while five other residents were present. The resident, who had diagnoses including muscle wasting, type 2 diabetes, infection of an amputation stump, and heart failure, was seated in a wheelchair at the time. The resident's medical record indicated intact cognition and no rejection of care. The nurse stated she administered the injection in the common area because the resident was already out of his room and believed it was acceptable, as she had previously given oral medications in similar settings. She was unaware that this practice was inappropriate and had not been informed that injections should not be administered outside a resident's room. The facility's Wing One Unit Manager confirmed that nurses were expected to administer medications and perform treatments inside residents' rooms to ensure privacy. The Unit Manager also observed the injection being administered in the common area and noted that, despite the nurse being new to the facility, she had significant nursing experience and should have known the proper procedure. Review of the facility's policies and the nurse's orientation documentation confirmed that privacy was to be provided when administering medications and that the facility aimed to protect and promote resident rights and dignity.

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