Failure to Knock Before Entering Resident Room During Medication Pass
Penalty
Summary
Facility staff failed to maintain resident privacy when an LPN entered the room of Resident #26 without knocking or waiting for permission during medication administration. Resident #26 had been admitted on an unspecified date with multiple diagnoses, including schizoaffective disorder, visual loss, mood disorder, psychosis, prediabetes, toxic effect of carbon monoxide, cocaine dependence, major depressive disorder, homelessness, adult failure to thrive, and post-traumatic stress disorder. On 02/25/26 at 9:00 A.M., observation showed LPN #133 prepared medications for Resident #26 at the medication cart in the hallway and then walked directly into the resident’s room without knocking on the door. In an interview at that time, LPN #133 confirmed she had not knocked or waited for a response before entering, despite the facility’s written privacy policy stating that staff would provide residents with their right to privacy and security and would knock on doors for permission to enter. This deficiency affected one of five residents observed during medication administration and was identified through observation, medical record review, staff interview, and review of the facility’s privacy policy dated 06/19.
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