F0760

E

Failure to Administer Significant Medications as Ordered and Within Required Time Frames

Momence, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that significant medications were administered as ordered, including repeated late, missed, and incorrectly transcribed doses for multiple residents. One cognitively intact resident with malignant lung neoplasm, bilateral above-knee amputations, and chronic painful skin disease reported frequently not receiving his 9:00 PM medications until around midnight and his morning medications until around 11:00 AM or 12:00 PM, stating that he needed them and that not getting them on time was making him sicker. On one observed day, his baclofen and gabapentin, ordered three times daily and scheduled for 9:00 AM, 5:00 PM, and 9:00 PM, were actually administered at 11:24 AM, 4:35 PM, and 8:10 PM, respectively. At the time of observation, the eMAR system showed his medications as overdue, and the nurse confirmed that 14 residents on the hall had overdue medications.

Another resident with diabetes and hyperglycemia had short-acting insulin ordered three times daily before meals and long-acting insulin once daily in the evening. On the observed day, the 7:00 AM and 11:00 AM short-acting insulin doses were both signed as administered at 11:35 AM. For the long-acting insulin scheduled at 8:00 PM, the audit report showed that several consecutive evening doses were actually given the following mornings between approximately 6:00 AM and 7:00 AM, with one dose documented as refused at 8:00 PM but administered the next morning at 6:48 AM, and another dose given about 14 hours after its scheduled time. A resident with schizoaffective disorder, bipolar type, and recurrent major depressive disorder had benztropine, clozapine, and lithium ordered at specific times (twice daily or three times daily). On one day, all three 9:00 AM doses were signed as administered at 12:58 PM, and the 1:00 PM lithium dose at 12:59 PM; on the previous day, the 9:00 AM doses were signed at 2:58 PM and the 1:00 PM lithium dose at 2:20 PM.

A resident with diabetes with hyperglycemia and foot ulcer, combined heart failure, and hypertension had daily amlodipine and lisinopril ordered at 9:00 AM with parameters to hold for low systolic blood pressure, and insulin orders including long-acting insulin at bedtime and short-acting insulin before meals. On the observed day, the RN stated she began passing medications around 11:00 AM, and the resident’s blood pressure had last been taken the previous afternoon; the 9:00 AM hypertension medications were administered around noon. The prior day’s 9:00 AM hypertension medications were administered at 3:00 PM. For this resident’s insulin, an 11:00 AM short-acting insulin dose on one date was administered at 6:20 PM, and another 11:00 AM dose on a different date at 2:23 PM. The bedtime long-acting insulin scheduled for 9:00 PM was repeatedly administered the following mornings between about 6:00 AM and 7:00 AM on several consecutive days, with one dose given approximately 14 hours after its scheduled time.

A resident with malignant brain neoplasm and epileptic seizures had levetiracetam and lacosamide ordered twice daily, twelve hours apart at 9:00 AM and 9:00 PM. The audit report showed a pattern of significant deviations from the ordered schedule: on multiple consecutive days, 9:00 PM doses were administered the following mornings between about 6:00 AM and 7:00 AM, 9:00 AM doses were delayed by several hours into the afternoon or evening, and on one day three doses were given within approximately 15 hours. On another day, the 9:00 PM doses were not signed off as administered at all, and the next day’s 9:00 AM doses were given about 22 hours after the prior morning dose. Another resident with functional quadriplegia, dysphagia, and a history of acute respiratory failure and pneumonia was discharged from the hospital with instructions to start levofloxacin 750 mg daily for five days. In the facility, the order was transcribed incorrectly as levofloxacin 750 mg twice a day via gastrostomy tube every five days, and the MAR showed 9:00 AM and 5:00 PM doses signed as administered on two non-consecutive days instead of once daily for five straight days. The audit report further showed that on one of those days, the 9:00 AM dose was administered at 5:19 PM and the 5:00 PM dose at 7:13 PM, less than two hours apart. The facility’s medication error policy defined medication not administered within an allowed time frame greater than one hour from its scheduled time or missed medications as administration-based errors, which were present in these cases.