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F0658
D

Failure to Ensure Proper Medication Administration and Monitoring

Chicago, Illinois Survey Completed on 05-30-2025

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

The facility failed to follow professional standards of care in medication administration for one resident. The resident had an active physician order for Gabapentin 300mg to be given orally three times a day for nerve pain. During an observation, a bottle containing thirty-four Gabapentin capsules was found on the resident's bedside table, and the resident stated he had informed the nurses that he did not want the medication. The registered nurse present acknowledged that the capsules were Gabapentin and that nurses should have monitored the resident to ensure the medication was swallowed. Interviews with nursing staff, including the Director of Nursing and a registered nurse who had administered the medication, confirmed that it was their expectation and facility policy for nurses to remain with residents to ensure medications are swallowed. However, the Medication Administration Record indicated that nurses had been signing off that the Gabapentin was given, despite the accumulation of capsules at the bedside. The facility's policy specifically requires staff to remain with residents during medication administration to ensure compliance.

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