F0684

D

Failure to Administer and Document Ordered Medications for a Resident

Palos Hills, Illinois Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer and document medications as ordered for one resident. The resident is an adult female with multiple diagnoses including neuromyelitis optica, difficulty in walking, muscle disorder, lack of coordination, cognitive communication issues, depression, spinal stenosis, anemia, edema, hyperlipidemia, tremor, aphasia, anxiety, dysthymic disorder, and kidney/ureter disorder. Her BIMS score indicated moderate cognitive impairment, though she was observed to be alert, oriented, groomed, and able to make her needs known. On one day, the resident reported she had not received her medication and that the nurse had said she would return but did not. The following day, the resident again stated she had not received her morning medications the previous day as scheduled.

Interviews with staff and review of the Medication Administration Record (MAR) and progress notes showed that multiple scheduled medications were not documented as given and no reasons were recorded for the omissions. The DON stated that medications are to be given within one hour before or after the scheduled time, and that if not given, the nurse must notify the provider and resident/family and document the reason on the MAR. One LPN reported she had given the resident’s 9:00 a.m. and 12:00 p.m. medications but likely forgot to document them due to being busy, while another LPN stated that blank MAR boxes indicate medications were not given. The MAR for the resident showed missed 9:00 a.m. doses of famotidine, hydrocodone-acetaminophen, nystatin powder, primidone, and buspirone, and a missed 12:00 p.m. dose of vitamin D3, with no documented reason for non-administration, contrary to the facility’s medication administration policy and nursing job description.