F0759

D

Medication Administration Errors Resulting in Elevated Error Rate

Hazel Crest, Illinois Survey Completed on 08-14-2025

Penalty

No penalty information released

Summary

The facility failed to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 25 medication opportunities, resulting in an 11% error rate. During a medication pass observed with an LPN on the first floor, a female resident with a diagnosis of polyneuropathy received only part of her ordered gabapentin regimen. The active physician orders directed that she receive gabapentin 600 mg plus an additional 100 mg tablet three times daily (total 700 mg TID) for neuropathy. However, the nurse administered only the 600 mg tablet and did not give the 100 mg tablet, yet documented in the MAR that the 100 mg dose had been given.

In a separate observation with the same LPN, another resident with essential primary hypertension had a blood pressure of 101/63 and heart rate of 97 prior to medication administration. The nurse administered five medications and held chlorthalidone 25 mg due to the systolic blood pressure of 101. The physician’s orders specified that chlorthalidone should be held if SBP was less than 120, and that valsartan (80 mg total) and amlodipine 5 mg should be held if SBP was less than 110. Observation showed that valsartan and amlodipine were not administered, but the MAR reflected that both medications were signed out as given with the documented blood pressure of 101/63, and chlorthalidone was not given despite the order parameters. The DON stated that her expectations for nurses during medication administration include following the five rights of medication administration, proper hand hygiene, and maintaining resident privacy, and the facility’s medication administration policy requires medications to be administered in accordance with physician orders and documented by the same licensed nurse who administers them.