F0725

E

Insufficient RN Staffing on Respiratory Unit Leading to Widespread Late Medication Administration

Elmwood Park, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on the third-floor respiratory (ventilator) unit to meet resident needs, resulting in widespread late medication administration. The third floor housed 32 residents, all dependent on staff for all or some daily needs, including 16 residents on ventilators, 29 with tracheostomies, 22 with gastrostomy tubes, and 15 with wounds. Facility staffing records from 3/9/26–3/25/26 show that only two licensed nurses were scheduled per shift on this high-acuity respiratory unit, consistent with the facility assessment and staffing plan that identified two licensed nurses per unit and per shift. On the date reviewed, the schedule showed two RNs (one agency) assigned to the third floor, and the DON confirmed there had been a call-off and that one RN came in to cover until the agency nurse arrived.

On the morning in question, one RN reported still having several residents left to receive their medications and stated that medications would be late, explaining that the volume of residents with gastrostomy tubes made medication administration time-consuming due to required checks and preparation. This RN stated that medications were late every day on that floor and that a third nurse was needed. A floor manager RN reported being asked to come in temporarily to help until the agency RN arrived and acknowledged that most residents’ medications, scheduled for 9:00 a.m. and due by 10:00 a.m., were not given by the due time; the floor manager passed medications for only two residents and then stayed to help the agency nurse. The agency RN stated that they had just arrived, were receiving report, had 19 residents assigned, and still had 17 residents needing their morning medications after the due time, confirming that these medications would be late.

Medication Administration Audit reports for the third floor on the same date showed that 16 of 32 residents received medications late, affecting residents assigned to both RNs. Multiple residents with complex conditions, including respiratory failure, ventilator dependence, tracheostomies, gastrostomy tubes, epilepsy, diabetes, pressure ulcers, quadriplegia, hemiplegia, anoxic brain damage, COPD, and other serious diagnoses, had scheduled morning medications administered from 21 minutes to more than three hours past the scheduled times. The DON acknowledged that medications are expected to be given within one hour before or after the scheduled time, affirmed that administration more than one hour past the scheduled time is a timing medication error requiring physician notification, and nonetheless stated a belief that two nurses were sufficient for the unit. Additional staff who regularly worked on the respiratory unit, including an RN, an LPN, and the Infection Preventionist, reported that there were not enough nurses on the third floor, described the residents as very acute with extensive ventilator, trach, and tube-feeding needs, and stated that the workload made it difficult to do more than pass medications and impeded timely completion of other nursing tasks. These observations and records demonstrate that the facility did not ensure sufficient nursing staff with appropriate competencies to meet the assessed needs of all residents on the respiratory unit, contrary to its own staffing, medication administration, and resident rights policies.