F0684

D

Failure to Administer Ordered Antihypertensive Medication and Inaccurate MAR Documentation

Chicago, Illinois Survey Completed on 02-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident received ordered antihypertensive medication as prescribed. The resident is an alert female with diagnoses including COPD, bipolar disorder, hypertension, major depressive disorder, and reflux. Her POS dated 1/13/2026 ordered Amlodipine Besylate 5 mg by mouth in the morning for hypertension, and on 11/09/2025 she also started Lisinopril 5 mg by mouth in the morning for hypertension. The resident reported that she is on two blood pressure medications and stated that on 2/16/2026 she did not receive one of her blood pressure medications because the facility did not have it available, identifying V4 as the nurse on duty.

V4 confirmed that one of the resident’s blood pressure medications was not available and stated that she reordered it but did not contact the physician. V4 acknowledged that she documented on the February MAR that the medication was given, even though it was not, and that she did not check the convenience box or follow any procedure beyond reordering the medication. She stated she was not informed of the procedure for when medication is out and was unable to recall which blood pressure medication was missing. The DON (V2) stated that when a medication is out, the nurse is expected to obtain it from the electronic medicine machine or emergency medication cart and notify the physician that the resident did not receive the medication. Review of the February 2026 MAR showed that V4 had marked the medication as administered on 2/16/2026, despite the resident’s report and V4’s admission that the medication was not available, which is inconsistent with the facility’s Medication Administration Policy requiring medications to be administered in accordance with physician orders and medication/treatment errors to be reported and documented.