F0759

D

Medication Administration Outside Time Window Resulting in Elevated Error Rate

Joliet, Illinois Survey Completed on 12-12-2025

Penalty

No penalty information released

Summary

The facility failed to ensure medications were administered in accordance with physician orders and within the facility’s defined medication administration window, resulting in a medication error rate of 10.53% (4 errors out of 38 opportunities), exceeding the required rate of less than 5%. One cognitively intact resident with diagnoses including atrial fibrillation, hypertension, schizophrenia, cognitive communication deficit, pain, and weakness did not receive medications as ordered. On a specified date, an RN delayed the resident’s scheduled 9 AM medications because the resident was nauseous and subsequently prepared and administered them at 1:05 PM, outside the facility’s one-hour window around the prescribed time. The RN then documented the medications as administered in the electronic record between 1:15 PM and 1:19 PM.

Medication reconciliation and record review showed that Amantadine HCl and Docusate Sodium, each ordered twice daily at 9 AM and 5 PM, and Gabapentin 300 mg, ordered three times daily at 9 AM, 1 PM, and 5 PM, were all administered at 1:05 PM instead of at the ordered 9 AM time. The 1 PM dose of Gabapentin was also signed out at 1:19 PM. A daily multivitamin ordered once a day at 9 AM was not administered as ordered, despite being signed off in the record. Interviews with an LPN, the DON, and an NP confirmed that the facility’s medication administration window for 9 AM medications was 8 AM to 10 AM, and that medications given outside this window required contacting the physician or NP for clarification, which was not documented for this resident. The facility’s policy required medications to be administered according to physician orders and within one hour of prescribed times, which was not followed in this instance.