F0602

E

Misappropriation and Improper Handling of Resident Medications

Decatur, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the misappropriation and improper use of resident medications and failure to follow medication administration policies. A facility policy stated that drugs ordered for one resident must not be used for another, and the abuse prevention program defined misappropriation of resident property as wrongful use of a resident’s belongings without consent. Despite this, an LPN reported that after obtaining a blood glucose of 49 for one resident, she determined that the resident was out of insulin and decided to “borrow” insulin from another resident, acknowledging she had been taught not to do so. She withdrew 2 units of Novolog and 10 units of Lantus from one resident’s insulin vials and administered them to another resident, even though the facility had a backup medication system that included insulin. Prescribing information for Novolog specified that insulin vials should not be shared between different patients, even with different needles.

The deficiency also includes improper medication handling and preparation practices. During observation of medication storage on one hall, four pre-poured medications in pill cups were found stacked on the counter, intended for a later medication pass. The LPN on duty stated she was PRN and not aware of the facility’s policies or procedures and confirmed that the pre-poured medications were for multiple residents, including pantoprazole, sucralfate, Xarelto, warfarin, and apixaban scheduled for administration several hours later. The DON later confirmed with the LPN that she had pre-poured these medications and stated that medications should not be pre-poured, indicating that the observed practice was inconsistent with facility expectations and contributed to the identified deficiency.