F0759

D

Late and Omitted Medication Administration Due to Inadequate Nurse Staffing

Alton, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications within the specified time frames and as ordered for three residents during a medication pass. On 2/19/26, an RN was observed administering multiple morning medications scheduled for 9:00 AM to three residents between 11:36 AM and 12:04 PM. For one resident, loratadine, nicotine patch, metformin, atorvastatin, buspirone, famotidine, hydrochlorothiazide, lisinopril, Seroquel, and a mometasone furoate inhaler, all ordered for 9:00 AM, were not administered until 11:36 AM. This resident had diagnoses including paranoid schizophrenia, hyperlipidemia, hallucinations, mild intellectual disabilities, depression, shortness of breath, and weakness, and the care plan included interventions to administer statin, psychotropic, and respiratory medications as ordered.

A second resident’s medications, including Anora Ellipta inhaler, atorvastatin, cetirizine, cholecalciferol, lisinopril, a multivitamin with minerals, levetiracetam, and metformin, all ordered for 9:00 AM, were not administered until 11:44 AM. This resident, who was cognitively intact, reported that nurses were sometimes late with medications. The resident’s diagnoses included cerebral infarction, COPD, type 2 DM, HTN, hyperlipidemia, seizures, MDD, and chronic bilateral lower extremity embolism and thrombosis, and the care plan documented risks related to diabetes, hypertension, statin use, psychotropic use, COPD, and seizure activity, with interventions to administer medications as ordered.

For a third resident, iron sulfate, divalproex, duloxetine, cyanocobalamin, metoprolol, Abilify, furosemide, potassium chloride, Entresto, and hydroxyzine, ordered for 9:00 AM (with Entresto ordered at 7:00 AM and 7:00 PM), were not administered until 12:04 PM, and dapagliflozin ordered for 9:00 AM was not available and therefore not given. This resident had multiple diagnoses including multiple sclerosis, pulmonary nodule, polyosteoarthritis, anemia, thyrotoxicosis, muscle spasm, hyperlipidemia, PTSD, congestive heart failure, low back pain, hypokalemia, vitamin deficiency, anxiety disorder, and bipolar disorder, with a care plan calling for administration of statin and psychotropic medications as ordered. The RN administering medications appeared flustered and stated that only three nurses were working instead of the usual four, causing her to run behind and combine morning and 11:00 AM medications, and stated that having only three nurses was affecting the quality of care. The facility’s medication administration policy required medications to be given at the proper time and dose, with documentation and provider notification if medications were not given as ordered or not present.