F0755

E

Widespread Failure to Administer Medications According to Physician-Ordered Times

Chicago, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for timely medication administration for eight residents, resulting in repeated late or omitted doses. Nursing staff, including LPNs and RNs, reported being the only nurse on a unit, covering additional assignments, arriving late for shifts, and being unable to complete 9:00 AM medication passes within the accepted 8:00–10:00 AM window. One LPN stated that some 9:00 AM medications were given after 10:00 AM and acknowledged that late medications could mean residents’ pain or blood pressure were not well controlled. Another LPN reported arriving at 9:30 AM with no medications yet passed for her assignment and stated she would not be able to complete all 9:00 AM medications within the one-hour before/after window.

Multiple residents experienced late administration of scheduled medications across several days, as documented in the MARs and medication audit reports. One resident with intact cognition and diagnoses including PVD, seizures, schizophrenia, COPD-related conditions, and diabetes reported often not receiving medications as scheduled, sometimes three hours late, and described a day when all medications were delayed until early afternoon. This resident’s records showed repeated late administration of Gabapentin for neuropathic pain, Advair and Albuterol for tracheal stenosis and shortness of breath, with doses scheduled for morning, afternoon, and evening frequently given several hours after the ordered times. Another cognitively intact resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a prescribed 6:00 AM Lidocaine patch and reported shoulder pain rated 8/10; the patch was not observed in place. The same resident’s 9:00 AM medications, including Bactrim DS for UTI, Hydroxychloroquine, Metformin, Symbicort, and Gabapentin, were administered after 11:00 AM, and some medications such as Empagliflozin and Gabapentin were not available and therefore not given.

Additional residents with intact or impaired cognition and multiple chronic conditions also had late medication administration documented. One resident receiving psychotropic medications (Risperidone and Benztropine) and a bowel regimen had doses scheduled for 9:00 AM and 6:00 PM given several hours late on multiple days. Another resident with diabetes, hypertension, CKD, and anemia had Metoprolol, Metformin, Ferrous Sulfate, and Humalog insulin repeatedly administered beyond the ordered times, including insulin given well after the scheduled pre-meal time. A resident with neuropathic pain had Gabapentin doses scheduled three times daily administered late on several dates. Residents with seizure disorders and cardiovascular conditions had anticonvulsants (Divalproex, Levetiracetam), antihypertensives (Carvedilol), muscle relaxants (Baclofen), and other medications administered outside the one-hour before/after window, including one evening Levetiracetam dose given in the early morning of the following day. The DON and NP both stated that nurses are expected to follow the five rights of medication administration, that medications should be given within one hour before or after the ordered time, and that administration beyond this window is considered late and not following the physician’s order, consistent with the facility’s medication administration policy.

The facility’s own policy on administration procedures for all medications, dated 10/25/14, requires medications to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Interviews with the DON and NP confirmed that medications given more than one hour outside the ordered time are considered late and not in accordance with physician orders. Despite this, the documented MARs and audit reports for all eight residents show a pattern of late administration and, in some cases, omitted doses due to unavailability of medications, affecting pain medications, psychotropics, anticonvulsants, antihypertensives, antidiabetics, antibiotics, and respiratory medications. These actions and inactions by nursing staff, combined with staffing and scheduling issues described by the nurses, led directly to the failure to provide pharmaceutical services in accordance with physician orders for the affected residents.