F0760

E

Failure to Provide Ordered Muscle Relaxant Resulting in Significant Medication Error

Clinton, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a prescribed muscle relaxant for pain, Methocarbamol 750 mg three times daily, was not administered for multiple scheduled doses. The resident had diagnoses including wedge compression fracture of T9–T10 vertebra with routine healing, restless leg syndrome, chronic pain syndrome, muscle wasting and atrophy, and gait and mobility abnormalities. The resident’s MDS documented intact cognition (BIMS 15/15) and occasional, moderate pain that frequently interfered with activities and sleep. The December MAR showed repeated use of chart code 9 (Other/See Progress Notes) for the Methocarbamol doses scheduled at 6:00 a.m., 1:00 p.m., and 8:00 p.m. on multiple consecutive days, indicating the medication was not given as ordered.

Progress and administration notes documented that from 12/24 through 12/27, the Methocarbamol was repeatedly noted as “on order,” “awaiting pharmacy,” “out of medication,” or “medication unavailable,” resulting in missed doses over several days. During interview, the resident reported hurting almost constantly “deep down in the muscle,” stated that the muscle relaxer was not available or not given when scheduled, and reported that even with hydrocodone, they still experienced pain, noting that the combination of medications significantly affected their comfort. The DON acknowledged unawareness of the issue until review with the surveyor, stated there had been problems with the pharmacy sending medications, and confirmed on review of the MAR that the resident had missed several Methocarbamol doses in December, characterizing this as significant and more than a single delayed dose.