F0760

E

Widespread Late Administration of Significant Medications

Westmont, Illinois Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that significant medications were administered as ordered, within the accepted one-hour window before or after the scheduled time, for seven residents reviewed for medication administration. On one day, an LPN (V18) reported arriving after 10:00 AM due to scheduling confusion and did not begin administering scheduled morning medications until after 11:00 AM, completing the pass around 2:45 PM. Multiple residents complained of receiving their morning medications in the afternoon, and the Director of Nursing and Administrator both acknowledged that medications were not administered on time, contrary to physician orders and facility policy requiring medications to be given at the proper time.

For one resident with diabetes mellitus, asthma, heart disease, and cardiomyopathy, electronic records showed ordered Humalog insulin three times daily, sliding scale insulin with meals, insulin glargine every 12 hours, Advair HFA twice daily, and furosemide twice daily. The medication administration audit showed that scheduled morning insulin doses, sliding scale insulin, Advair, and furosemide ordered for early morning times were instead administered between mid-afternoon times. Another resident with aortic valve insufficiency, hypertensive disease, bursitis, facial cellulitis, and anxiety disorder had gabapentin, Xanax, and amoxicillin-clavulanate ordered for 9:00 AM, but the audit showed these were administered between early afternoon times. A resident with hallucinations, anxiety, and dementia, with orders for haloperidol and divalproex three times daily and memantine twice daily, had 9:00 AM medications administered after 11:00 AM.

Additional residents experienced similar delays. One resident with chronic pulmonary disease, end-stage renal failure on dialysis, and venous thrombosis/embolism had carvedilol, Advair inhaler, and apixaban ordered for 9:00 AM but administered in the late afternoon. Another resident with seizures, atrial fibrillation, hypotension, and chronic pain, ordered apixaban every 12 hours, levetiracetam twice daily, and Lyrica twice daily at 9:00 AM, received these medications early in the afternoon. A resident with heart failure, fibromyalgia, pulmonary embolism, and anxiety disorder, ordered alprazolam twice daily, gabapentin three times daily, losartan for hypertensive heart disease with heart failure, and apixaban twice daily at 9:00 AM, received them between mid- and late afternoon. A resident with chronic kidney disease and COPD, ordered fluticasone HFA every 12 hours/twice daily at 9:00 AM, received the medication in the early afternoon. These findings, based on resident interviews, EMR review, and medication administration audits, show that ordered morning medications were consistently administered several hours late for all seven residents.