F0600

J

Failure to Provide Ordered Medications and Notify Physician Resulting in Resident Death

Galesburg, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications and necessary services to prevent physical harm. A resident with complex cardiopulmonary conditions, including acute on chronic respiratory failure with hypercapnia, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, was admitted from a hospital with detailed physician orders for multiple medications and treatments. These included oxygen at 5 L via nasal cannula, diuretics (such as spironolactone and torsemide), bronchodilators and nebulizer treatments (including arformoterol, Breztri, ipratropium‑albuterol, and albuterol), steroids (prednisone), and several other maintenance medications and supplements. The facility’s own policies required that physician orders be entered within one hour of admission, that medications be available upon admission using the emergency drug kit or STAT safe if needed, and that pharmacy be contacted for STAT delivery when medications were not on hand.

Despite these requirements and the resident’s high‑risk medical status, the Medication Administration Record shows that on multiple days following admission, the resident did not receive numerous ordered medications at scheduled times. Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol (Breztri), clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol at various 8:00 a.m., 12:00 p.m., and 4:00 p.m. doses. These omissions were documented by the LPN as “unavailable.” The facility had an electronic STAT safe/automated dispensing cabinet stocked with several of these medications, including albuterol, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN acknowledged that she did not obtain medications for the resident from this machine on the days in question.

The LPN further stated that the resident’s medications had not arrived from the pharmacy and that the resident did not receive medications on those days, but she did not notify the physician or nursing management that ordered medications, including breathing treatments, diuretics, heart failure medications, and prednisone, were not being administered. Pharmacy records later showed that many of the resident’s medications were in fact delivered to the facility overnight and early morning, yet the LPN could not explain why certain medications, such as acetazolamide and Breztri, were still not administered after delivery. The primary physician and advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not being given and indicated that they would have modified the treatment plan or sent the resident back to the hospital if they had been informed. On the day of death, staff last spoke with the resident shortly before noon, and when the LPN went to administer medications late that morning, the resident was found without respirations or pulse and was pronounced expired. The facility and surveyors determined that the failure to administer prescribed medications as ordered, to use available medication resources, and to notify the physician and nursing administration of missed doses constituted neglect and resulted in actual harm and death, rising to the level of Immediate Jeopardy.

The facility’s own documentation and staff interviews confirmed that there was no timely escalation when medications were marked as unavailable, no documented physician notification regarding missed doses over multiple days, and no implementation of alternative interventions despite the resident’s complex cardiac and respiratory diagnoses. The DON verified that the resident did not receive multiple ordered medications on the identified days. The death certificate listed acute on chronic congestive heart failure and acute on chronic diastolic heart failure as the cause of death, with COPD as a significant contributing condition. The survey findings concluded that the deprivation of necessary medications and services, in violation of the facility’s abuse prevention and medication availability policies, constituted neglect and led to actual harm and death, resulting in an Immediate Jeopardy determination.

Removal Plan

• Director of Nursing reviewed all residents receiving prescribed medications as ordered.
• Director of Nursing reviewed all residents and identified no residents as having missed any doses of prescribed medications.
• All licensed nurses were educated by the Director of Nursing and provided access and instructions on how to obtain unavailable medications from the facility emergency medication kit (STAT Safe).
• Regional Nurse Consultant educated the Director of Nursing on medication administration and availability.
• Weekly match-back audits are completed for medication availability.
• All new admissions are reviewed to ensure medications are available and orders are in place using a checklist, which is reviewed daily during the clinical QA meeting.
• Licensed nursing staff were educated by the Director of Nursing on adherence to physician orders, timely resident assessment and documentation, physician notification when an ordered dose is missed, immediate notification and escalation to facility nursing administration for medication administration issues, and the facility Abuse and Neglect Policy related to administering prescribed medications to avoid physical harm.
• Director of Nursing created an audit tool to ensure compliance with medication administration and availability, assessment and documentation, physician notification and escalation to nursing administration, and staff knowledge of facility medication administration standards to avoid physical harm to residents.
• Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.
• Administrator or designee will audit licensed nurses to ensure compliance with medication administration standards to avoid physical harm to residents.