F0684

E

Widespread Failure to Administer Medications Within Policy Timeframes

Westmont, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications within one hour of the prescribed times as required by its own medication administration policy. The electronic medical record (EMR) and Medication Admin Audit Reports showed repeated late administration of scheduled medications for multiple cognitively intact residents, including psychotropic medications, diabetic medications, pain medications, and topical treatments. For one resident who served as Resident Council President, multiple medications scheduled for late afternoon and evening (such as Buspirone, Lamotrigine, Dicyclomine, Trazodone, Ezetimibe, Mirtazapine, Lomotil, Gabapentin, Propranolol, and topical creams) were consistently given more than an hour late over several days. Another cognitively intact resident reported that nurses stated they were busy and that residents would receive medications when the nurses could get to them; this resident’s Buspirone, Metformin, probiotic, buprenorphine/naloxone, Omeprazole, blood glucose checks, and multiple evening medications (including Lipitor, Gabapentin, insulin glargine, Trazodone, and Amitriptyline) were documented as administered significantly later than scheduled.

Additional residents reported and demonstrated similar patterns of delayed medication administration, particularly related to diabetic care and insulin timing. One cognitively intact resident stated her blood glucose check was not completed as scheduled because the nurse was out of testing strips and had to obtain them from another area; this resident’s insulin glargine and insulin lispro doses, as well as Dicyclomine, were administered well after their scheduled times. Another cognitively intact resident reported that afternoon-shift nurses passed medications late and described an instance where diabetic medications due at 6:00 PM were not received until 9:00 PM; documentation showed late administration of Atorvastatin, Humalog insulin, and Metformin. A further cognitively intact resident reported there were not enough nursing staff, and records showed her Carvedilol and blood glucose monitoring scheduled for 5:00 PM were not completed until 8:36 PM.

The pattern of late medication administration extended to residents with cognitive impairment and to other scheduled treatments. A severely cognitively impaired resident had ophthalmic solutions, topical cream, and blood glucose monitoring scheduled for early evening but administered more than two hours late, and on subsequent days had blood glucose checks and evening insulin and Terazosin given beyond the one-hour window. Another cognitively intact resident’s morning and noon medications, including insulin lispro, insulin glargine, Pregabalin, Buspirone, multiple oral medications, and buprenorphine, were administered significantly later than scheduled. One resident reported waiting more than two hours for medications and a CNA stated this resident complained that nurses might not give her medications because her room was at the far end of the hallway. Resident Council meeting minutes over several months documented resident concerns about call light response times, inconsistent follow-up, and staff turning off call lights before addressing residents’ requests. A nurse (LPN) reported being the only nurse for 32 residents, described being nonstop busy, unable to take breaks, and “just surviving every shift, ” in the context of the facility policy requiring medications to be administered within one hour of prescribed times.