F0684

J

Failure to Administer Ordered Medications and Notify Providers 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 ensure that a newly admitted resident received prescribed medications in accordance with physician orders. The resident was admitted from a local hospital after a prolonged hospitalization for acute on chronic respiratory failure with hypercapnia, acute respiratory distress, COPD, pulmonary hypertension, and acute on chronic diastolic congestive heart failure, among other diagnoses. Hospital discharge instructions and the facility’s October physician order sheet show that the resident was to receive multiple routine medications, including oxygen at 5 L via nasal cannula, diuretics (torsemide, spironolactone, acetazolamide), bronchodilators and nebulizer treatments (albuterol, ipratropium‑albuterol, arformoterol, Breztri), steroids (prednisone, fluticasone), psychotropic medication (clonazepam), and several other maintenance medications and supplements. Facility policy required that physician orders be entered within one hour of admission, that pharmacy be contacted after 4:00 p.m. for new admissions, and that medications be obtained from the emergency drug kit or STAT Safe if not yet delivered.

Despite these orders and policies, the resident’s Medication Administration Record shows that on two consecutive days after admission, the resident did not receive a wide range of ordered medications at scheduled times (8:00 a.m., 12:00 p.m., and 4:00 p.m.). Missed medications included aspirin, cyanocobalamin, docusate sodium, ferrous sulfate, fluoxetine, fluticasone, folic acid, prednisone, spironolactone, vitamin D3, acetazolamide, Budeson‑Glycopyrrolate‑Formoterol, clonazepam, hydroxychloroquine, torsemide, and ipratropium‑albuterol. These doses were documented by the LPN as “unavailable,” yet there is no documentation in the medical record that the physician was notified of the missed doses or that nursing management was informed. The facility had an electronic STAT Safe with several of the resident’s ordered medications stocked, including albuterol nebulizer solution, fluoxetine, prednisone, simvastatin, spironolactone, torsemide, and ipratropium, but the LPN later stated she did not obtain medications for the resident from this machine on the days in question.

Interviews confirmed that required escalation and communication did not occur. The LPN reported that when new admissions arrive, other staff typically enter orders and that medications are usually delivered between 8:00 p.m. and 10:00 p.m., but she stated the resident’s medications had not arrived and that the resident did not receive medications on the two days prior to death. She acknowledged she did not notify the physician or nursing management that the resident had not received any medications, including breathing treatments, diuretics, heart failure medications, or prednisone, and could not explain why she did not administer certain medications that had been delivered by pharmacy before the resident’s death. The attending physician and an advanced practice nurse both stated they were not notified that the resident’s medications were unavailable or not administered; the physician stated the medications, including multiple diuretics, nebulizer treatments, and steroids, should never have been placed on hold and that he expected medications to be available on the evening of admission or to be notified to modify the treatment plan. Pharmacy records showed that many of the resident’s medications were delivered late in the evening and early morning following admission, but the resident still did not receive them as ordered. The resident was last noted as alert with shortness of breath at times and requiring BiPAP and nebulizer treatments with oxygen; later, staff found the resident without respirations or pulse when attempting to administer medications, and the death certificate lists acute on chronic congestive heart failure and acute on chronic diastolic heart failure with COPD as contributing conditions. The facility’s failure to follow physician orders, obtain and administer available medications, and provide appropriate monitoring and response resulted in actual harm and death and was cited at the Immediate Jeopardy level.

The facility’s own policies and available resources underscore the inactions that led to the deficiency. The Medication Availability policy directed staff to enter orders promptly, contact pharmacy after 4:00 p.m. for new admissions, use the emergency drug kit or STAT Safe for needed medications, and obtain STAT or backup pharmacy delivery when medications were not in stock, with all administrations documented in the EMAR. The pharmacy’s posted hours and cutoff times, along with the STAT Safe inventory list, showed that many of the resident’s ordered medications were accessible through the automated dispensing cabinet. Nonetheless, the LPN did not use the STAT Safe to obtain medications, did not document any attempts to secure medications beyond marking them as unavailable, and did not escalate the issue to the DON or physician. The DON later verified that the resident did not receive multiple ordered medications on the days prior to death and that she had not been informed of the unavailability or non‑administration of these medications. These documented failures in medication procurement, administration, and communication formed the basis of the cited deficiency and Immediate Jeopardy determination.

Removal Plan

• Director of Nursing reviewed all residents to confirm they are receiving prescribed medications as ordered.
• All licensed nurses were educated by the Director of Nursing and provided access/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 medication availability processes.
• As part of QA activities, match-back audits are completed for medication availability.
• All new admissions are reviewed using a checklist to ensure medications are available and orders are in place; this checklist is reviewed 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 medication dose is missed, and immediate notification/escalation to facility nursing administration for any medication administration issue.
• An audit tool/process was created by the Director of Nursing to ensure compliance with medication administration and availability, assessment and documentation, physician notification, and escalation to nursing administration.
• Director of Nursing or designee will audit licensed nurses to ensure compliance with medication administration standards.