F0760

D

Failure to Administer and Document Critical Medications as Ordered

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite policies requiring medications to be administered as prescribed and properly documented. The facility’s Medication Administration General Guidelines Policy states that medications must be given according to prescriber orders, and any withheld, refused, unavailable, or untimely doses must be circled on the MAR with an explanatory note 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 the physician, and the Ombudsman Residents’ Rights Booklet states that the facility must provide services to keep residents’ physical and mental health at their highest practical levels.

For one resident with acute respiratory failure with hypoxia, tracheostomy status, gastrostomy status, encephalopathy, traumatic brain injury, and dilated cardiomyopathy with recent cardiac arrest, the care plan documented the need for anti‑seizure and cardiovascular medications as ordered. The December MAR showed multiple undocumented doses of Vimpat 100 mg via G‑tube, ordered twice daily, that were not recorded as given on several specified dates and times. The same MAR showed multiple undocumented doses of Keppra 750 mg via G‑tube, ordered every 12 hours, that were not recorded as given on several specified dates and times. Additionally, Hydrochlorothiazide 25 mg via G‑tube, ordered once daily for dilated cardiomyopathy, was not documented as given on multiple specified dates. The MDS Coordinator verified that this resident did not receive Vimpat, Keppra, and Hydrochlorothiazide as ordered and could not explain why.

For another resident with diffuse traumatic brain injury, tracheostomy status, essential hypertension, and acute respiratory failure, the care plan documented that the resident was on anticoagulant therapy for clot prevention, with an intervention to administer anticoagulant medications as ordered. The January MAR documented an order for Enoxaparin 30 mg/0.3 mL subcutaneously twice daily, starting on a specified date and discontinued on a later date, related to nontraumatic intracerebral hemorrhage in the brain stem. The MAR showed that multiple scheduled doses on several specified dates and times were not given. The facility nurse practitioner stated she had heard there were problems with medications not being available and that any time medication is not given as ordered it is a problem, specifically noting that missing medications such as Lovenox or Keppra could result in a serious issue. The MDS Coordinator confirmed that this resident did not receive Enoxaparin as ordered and stated the resident absolutely should have been getting what the doctor ordered, without knowing why the doses were missed.