F0684

D

Failure to Notify Provider of Missed Medications and Unassessed Use of Resident-Managed CGM

Joliet, Illinois Survey Completed on 12-12-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow provider notification requirements and medication administration parameters when ordered medications were missed, and failure to assess and obtain orders for the use of a continuous glucose monitoring (CGM) device. For one resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness, the RN reported that the resident refused her scheduled morning medications due to nausea and that Zofran was given. The RN then administered multiple medications, including amantadine, docusate sodium, and gabapentin, at approximately 1:05 PM, well outside the facility’s stated one-hour medication administration window for a 9 AM dose, without contacting the NP or MD for direction. Review of the physician order sheet confirmed these medications were ordered on twice-daily and three-times-daily schedules, and the medication administration audit showed the 9 AM gabapentin dose was documented at 1:16 PM and the 1 PM dose at 1:19 PM. There were no progress notes indicating the RN had notified the NP or MD about the missed or delayed doses.

Interviews with clinical staff and leadership confirmed that the nurse did not follow expected procedures for missed or delayed medications. The NP stated she was not contacted about any medications not administered to this resident and explained that if a resident was nauseous, she expected antinausea medication to be given and then, if the resident still could not take medications within the 8–10 AM window for a 9 AM dose, the nurse should call the provider to clarify which medications to administer, as it was not up to the nurse to decide due to differing medication half-lives and potential toxicity. Other nursing staff, including an RN and an LPN, stated that if a resident could not take medications at the scheduled time, they would notify the doctor to determine whether to skip or make up the dose, and the DON stated the nurse should contact the doctor if medications are held past the due time because it could result in an overdose if the next dose was due around the same time. The facility’s medication administration policy required medications to be administered within one hour of prescribed times, and the change in condition policy required physician or NP notification when deemed necessary or appropriate in the resident’s best interest.

A second deficiency involved the facility’s failure to obtain a physician’s order, perform an assessment, and develop care plan interventions for a resident’s use of a CGM system, despite having a facility policy on continuous glucose monitoring. The resident reported that she independently managed her CGM, obtained her own blood glucose readings, and informed staff of the results, and that staff did not check her blood glucose with facility equipment. An LPN stated that insulin and other interventions were provided based on the readings the resident reported from her CGM, and these readings and related interventions were documented in the EMR. The DON confirmed that the resident had a CGM, that staff obtained and documented glucose readings from the device, that the resident maintained and connected it herself, and that no competency assessment of the resident’s use of the CGM had been completed. The DON also stated staff did not have instructions or knowledge of how the device worked, and the Administrator confirmed there were no facility policies guiding assessment or nursing actions based on resident-managed CGM devices. Record review showed there was no physician order for self-directed CGM use, no care plan interventions, and no documented assessment of the resident’s use of the CGM, despite a facility CGM policy requiring a physician’s order and adherence to manufacturer instructions.