F0656

D

Failure to Accurately Implement Care-Planned Medication Validation and Documentation

Reseda, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involved the facility’s failure to implement a resident’s comprehensive care plan related to medication validation and documentation. The resident, who had intact cognition and was independent with ADLs, had diagnoses including Parkinson’s disease, hypotension, and bipolar disorder, and an order for pyridoxine HCL 25 mg, 0.5 tablet by mouth once every seven days for vitamin B6 deficiency, with monitoring for neurologic symptoms of excess vitamin B6. The resident’s care plan, initiated earlier and last revised in August, identified that the resident’s POA had episodes of denying or forgetting requests made, including for medications or supplements, and included an intervention for licensed nurses to discuss medications with the resident and to validate and initial in the medication sheets the medications and times of administration.

Record review showed that the MAR documented pyridoxine as scheduled and administered on four Thursdays in December, and a separate medication list created by the facility to validate that the resident received medications at scheduled times showed pyridoxine 25 mg, 0.5 tablet every seven days on Thursday at 9 a.m., marked with a check on a specific December date. During interview and concurrent record review, the LVN acknowledged that he had mistakenly documented on the medication list that pyridoxine was administered on that date, while confirming the resident did not actually receive the medication. The DON confirmed that the medication list was intended to validate that medications were given at scheduled times and that the LVN had checked pyridoxine as administered on a Wednesday, although it was ordered for weekly Thursday administration, and that this process was part of the care-planned intervention for validating medications and administration times.