F0755

E

Failure to Provide and Administer Ordered Medications as Prescribed

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that physician‑ordered medications were available and administered as prescribed for multiple residents, despite policies requiring timely receipt and accurate records of medication orders and administration. Facility policies state that medications must be received from the pharmacy on a timely basis, administered in accordance with prescriber orders, and that any withheld or unavailable doses must be documented with explanatory notes and physician notification if three consecutive doses of a vital medication are missed. RN and LPN job descriptions require them to prepare and administer medications as ordered by physicians, and the Ombudsman Residents’ Rights Booklet states that the facility must provide services to keep residents’ physical and mental health at their highest practicable levels.

One cognitively intact female resident with multiple diagnoses including a recent periprosthetic fracture, left femur fracture, fibromyalgia, osteoporosis, and diabetes had a care plan for potential pain related to recent fracture, surgery, and fibromyalgia, with interventions to administer medications as ordered and assess for pain. She had a physician order for Hydrocodone‑Acetaminophen 5‑325 mg every six hours for pain. Her MAR shows that the scheduled dose on one evening was not administered, and subsequent notes by an LPN document that the medication was unavailable in the cart and then on order. From that evening through several days, all 12 scheduled doses of Hydrocodone‑Acetaminophen were not administered, with repeated documentation that the medication was on order or unavailable. A health status note indicates the prescription was faxed to the physician and the facility was awaiting refill. The resident reported being in severe pain, crying out, and being told by staff that she was out of pain medication and that a script needed to be signed. The interim DON confirmed that all scheduled doses during that period were missed and that there was no documentation of nursing staff notifying a physician to obtain same‑day delivery or an alternative order.

Another resident’s MAR for an entire month shows 18 missed scheduled doses of multiple physician‑ordered medications, including an anticoagulant, nutritional wound supplement, anticonvulsants, antihypertensive, antiepileptic, and stimulant. These missed doses were left blank or referenced nursing notes that documented the medications as on order or not available. A third resident with an order for Prazosin 1 mg by mouth every evening for antihypertensive treatment did not receive six of nine scheduled doses over several days, with follow‑up notes again stating the medication was on order and awaiting pharmacy. A fourth resident diagnosed with oral candidiasis had an order for Nystatin oral suspension to be swabbed in the mouth four times daily; the MAR shows that 21 of 27 scheduled doses over several days were not administered, with notes indicating the medication was on order or not available. A progress note by the nurse practitioner documents that the resident had not been receiving the Nystatin and that the facility was still waiting on the pharmacy, and the nurse practitioner later stated she had not been notified that the ordered Nystatin could not be obtained. An agency LPN reported that medications are often missing or on order and that many carts have medications that are out, and the assistant DON confirmed that several residents had not been receiving scheduled medications and that no one had been auditing medication administration prior to the survey.

Overall, the survey findings show repeated instances where scheduled medications, including pain medication, anticoagulants, antihypertensives, anticonvulsants, antiepileptics, nutritional supplements, stimulants, and antifungal therapy, were not administered as ordered because medications were unavailable or on order. Documentation frequently noted that medications were on order or not available, but there was no evidence of timely physician notification or effective follow‑through to prevent gaps in administration, despite facility policies requiring such actions. These inactions and failures in ordering, receiving, and administering medications led to multiple residents not receiving their prescribed treatments over extended periods.