F0755

E

Improper Controlled Drug Security and Medication Administration/Documentation Failures

Chicago, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in pharmaceutical services, including improper storage and security of controlled substances and inaccurate controlled drug documentation. A nurse left an unlocked medication cart unattended in a hallway outside a resident’s room, with the cart’s lock not engaged and the narcotic bin accessible. The surveyor was able to open the drawers, including the drawer containing the locked narcotic bin, and observed a set of keys with a blue spring keychain left on top of the cart. When the nurse returned, the nurse confirmed responsibility for the cart, acknowledged that only nurses should have access, and verified that the keys left on top of the cart included the keys to both the medication cart and the narcotic bin, which contained multiple controlled medications such as tramadol and morphine. This conduct did not follow the facility’s policies requiring all drugs and biologicals to be stored in locked compartments and controlled substance keys to be maintained by the nurse who confirmed the count.

The facility also failed to maintain accurate controlled substance records for a resident receiving clonazepam, a controlled medication. During a review of the narcotic count on a medication cart serving about 15 residents, the Controlled Drug Receipt/Record/Disposition Form for one resident’s clonazepam documented that 26 tablets should remain, but the blister pack contained only 25 tablets. The agency nurse stated that the medication was an evening dose and had not been administered by that nurse, and that the narcotic count had been done with the outgoing nurse at shift change without noticing the discrepancy. The facility’s policies require controlled substances to be counted at the end of each shift by the oncoming and outgoing nurses together, with any discrepancies documented and reported, and the count confirmed against individual controlled substances.

Another deficiency involved improper medication administration practices, including leaving medication at the bedside and failing to ensure medications were administered and documented as ordered. One resident was observed lying in bed with a medication cup containing a white oval tablet on the bedside table. The resident stated not knowing what the medication was and believed it had been placed there while sleeping. When informed there was medicine present, the resident picked up the tablet and ingested it, again stating not knowing what the medication was and that they take medications even when they do not know what they are. The assigned RN confirmed that medication should not have been left at the bedside. The facility’s policies require that medications be administered safely and timely as prescribed, that nurses stay with residents until medications are swallowed, and that administration be documented immediately after giving each medication.

The report further documents failures to administer medications as ordered by the physician and to document administration on the medication administration record (MAR/eMAR). One resident with congestive heart failure had a physician’s order for bumetanide (Bumex) 3 mg with varying frequencies over the stay. The resident’s weight increased from 115 lbs to 127 lbs in one day and remained elevated over subsequent days. The MAR showed that bumetanide 3 mg was not documented as administered twice on one date and once on each of two subsequent dates, despite orders for twice-daily dosing during that period. Educational material from the American Heart Association included in the record describes edema and weight gain as common in heart failure and identifies diuretics such as bumetanide as medications used to reduce excess fluid.

Additionally, MARs for multiple residents over December and January showed multiple medications not documented as administered (not initialed or signed) in accordance with physician orders. The DON stated that medications must be administered as ordered, that nurses must document administration immediately after giving medications on the eMAR, and that blank documentation means administration cannot be proven. The facility’s Documentation of Medication Administration and Administering Medication policies require that a nurse or certified medication tech document each medication after it is given and before administering the next medications, and that only appropriately licensed or permitted personnel prepare, administer, and document medications. These documented omissions and failures in storage, administration, and documentation form the basis of the cited pharmaceutical services deficiencies affecting several residents receiving medications in the facility.