Santa Rosa Post Acute

During a concurrent interview and record review on 9/2/25 at 11:24 a.m., the Infection Preventionist (IP) reviewed Resident 1's, Resident 2's, and Resident 3's August 2025 MARs and confirmed all three residents had missed doses of their medications.During a second interview and concurrent record review on 9/2/25 at 12:10 p.m., the IP stated licensed nurses are expected to check the facility's emergency medication stock for the ordered medication.

The licensed nurses are also expected to call the pharmacy to confirm a delivery date and time, then call the physician to notify him of the issue.

The physician can then decide whether to order a substitute or confirm that the delay of medication administration is okay.

Lastly, the licensed nurses are then expected to document what they did and any instructions they were given in the resident's chart.

The IP also stated the pharmacy was located close by so most medications could be delivered the same day; however, if the order is placed at night, the medication would be delivered the following morning.

The IP reviewed Resident 1, Resident 2, and Resident 3's progress notes and confirmed there was no documented evidence the pharmacy nor the physician was called.

The IP also reviewed the list of medications available in the facility's emergency medication stock and found only the lidocaine patch was available.

The IP stated the nurse could have administered the lidocaine from the facility's emergency medication stock.

During an interview with the acting Director of Nursing (DON) and the Administrator (ADM) on 9/2/25 at 2:36 p.m., the DON confirmed if a medication was missed then it is considered a medication error and could have negatively affected the health of the residents. A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

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