F0759

D

Failure to Follow Medication Administration Policies and Physician Orders

Chicago, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow the facility’s medication administration policies and physician orders, resulting in a medication error rate of 19.35% (6 errors out of 31 opportunities) for one resident. A registered nurse (V25) prepared and administered multiple oral medications for resident R61 by placing 12 tablets together in a small cup, transferring them to a larger cup, and mixing them with applesauce, rather than administering them one at a time as outlined in the facility’s oral medication policy. During administration, the resident had difficulty swallowing, repeatedly spit out tablets, and the nurse left the room before ensuring all medications were swallowed, contrary to policy requiring the nurse to remain until all medications are taken. Two partially dissolved tablets were spit out onto the bed, identified by the nurse as vitamin C and aspirin, and then discarded in a sharps container.

The facility also failed to follow physician orders and internal procedures regarding medication form, positioning, and timing. R61 had a physician order to crush appropriate medications, but the nurse initially administered whole tablets mixed in applesauce until the family member reminded her that medications needed to be crushed for the resident to tolerate swallowing. For the ordered albuterol nebulizer treatment, the nurse placed the resident leaning to the right and kept the nebulizer in a position that did not allow full delivery of the medication; visible mist stopped partway through the treatment while liquid medication remained in the nebulizer chamber. The nurse then discarded the remaining medication in the sink, despite the facility’s nebulizer policy requiring the resident to be in semi-Fowler position and the nebulizer to be kept vertical and used until the medication is gone.

In addition, the nurse did not adhere to physician orders and facility policy regarding insulin and other time-sensitive medications. The nurse administered 2 units of insulin lispro subcutaneously without performing a blood sugar check immediately prior to administration, stating that the blood sugar had been checked earlier and was 200. Physician orders required insulin lispro and glimepiride to be given with meals, and pantoprazole to be given before breakfast, but these medications were not administered in alignment with the facility’s mealtime schedule and the allowed 60-minute window before and after the scheduled time. Specifically, pantoprazole ordered before breakfast was scheduled at 9:00 a.m., after the 7:45 a.m. breakfast, and glimepiride and insulin lispro were not administered with meals as ordered, despite the resident having elevated blood sugars on multiple recent dates. These actions and inactions collectively demonstrate noncompliance with the facility’s medication administration policies and physician orders for R61.