F0760

G

Medication Transcription, Timing, and Administration Failures Affecting Three Residents

Clinton, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in medication management, including inaccurate transcription of an antipsychotic order, improper timing of an antiparkinsonian medication in relation to meals, and failure to ensure medications were actually taken by a resident. One resident with diagnoses including Type II diabetes, Alzheimer’s dementia, repeated falls, and major depression had a psychiatric visit on 12/10/25, during which the psychiatric provider ordered continuation of Quetiapine 50 mg daily for agitation related to dementia and added Quetiapine 25 mg every 6 hours PRN. However, the resident’s Medication Administration Record and current physician order sheet show that the scheduled Quetiapine 50 mg dose was discontinued in error on 1/28/26, and no PRN doses were administered. As a result, the resident missed 13 consecutive days of the antipsychotic until the surveyor identified the error. During this period, staff and the psychiatric provider described escalating agitation, aggressive behavior, cursing, shouting, refusal of care, and isolation, and the psychiatric PA stated it was never the intention to stop the Quetiapine and that abrupt cessation likely contributed to the behavioral escalation.

Another resident, with diagnoses including depressive disorder, history of right femur fracture with hip replacement, and Parkinson’s disease, was ordered Carbidopa/Levodopa (Sinemet) 25/100 mg three times daily for Parkinson’s disease with dyskinesia and fluctuations. The resident’s family reported being instructed that the medication should be given 30–60 minutes prior to food because high-protein foods interfere with absorption, but stated that in the facility it was sometimes given before, sometimes after, and sometimes with meals. The MAR documented the three-times-daily Sinemet order without specific meal-related instructions, and the primary physician confirmed that timing 30–60 minutes prior to meals is crucial for absorption and that incorrect timing could be causing increased Parkinson’s symptoms. The acting DON confirmed that this resident’s Sinemet had been administered without regard to meals, while nursing staff described a general practice of administering medications within one hour before or after scheduled times due to workload.

A third resident, documented as cognitively intact, reported that on a Sunday evening an agency nurse left all of the resident’s evening medications in a cup on the dresser for the empty bed next to the resident, and the resident did not remember to take them. The next day, an activity assistant found the untouched medications, and the acting DON verified they were all of the resident’s 8:00 p.m. medications. The MAR showed that these evening medications included multiple critical drugs: Amlodipine and Lisinopril (antihypertensives), Atorvastatin (anticholesterol), Eliquis (anticoagulant), Keppra (antiseizure), Metoprolol (beta blocker), as well as Famotidine and Senna. The administrator confirmed that the resident did not receive any of the scheduled 8:00 p.m. medications that night because they had been left in the cup on the dresser by the agency nurse. The facility’s policy on entering and processing physician orders requires licensed nurses to confirm and complete instructions for new orders, but the documented events show failures in accurately maintaining and administering ordered medications for these residents.