145781
03/14/2025
Generations at Applewood
21020 Kostner Avenue Matteson, IL 60443
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on interview and record review the facility failed to follow their control substance policy and ensure the medication hydrocodone 5-325 milligrams are documented and accounted for, for two of two residents (R4 and R5) reviewed for controlled medications.
Findings include: 1. On 3/12/25 at 3:20pm during survey tour with assist from V4 (Director of Nursing) to observe the practice of counting control substance/narcotics, R4's control drug receipt/record/disposition form was observed to have documented discrepancy below date of 2/18/25. R4's control drug receipt record denotes Hydrocodone 5-325mg was signed out on 2/4/25 at 9a.m., 1p.m., and 9p.m. On 2/5/25 at 10a.m. On 2/6/25 at 2pm, 10pm. On 2/7/25 at 8a.m. and 4p.m. On 2/11/25 at 9a.m, 4p.m. On 2/12/25 at 9a.m, 10p.m. On 2/13/25 at 9a.m, 10p.m, 9p.m. On 2/18/25 at 9a.m, 2p.m. R4's Medication Administration Record dated February 2025 was reviewed, there is no documentation denoting that hydrocodone 5-325mg was administered to R4 on 2/4/25 at 9a.m., 1p.m., and 9p.m. On 2/5/25 at 10a.m. On 2/6/25 at 2pm, 10pm. On 2/7/25 at 8a.m. and 4p.m. On 2/11/25 at 9a.m, 4p.m. On 2/12/25 at 9a.m, 10p.m. On 2/13/25 at 9a.m, 10p.m, 9p.m. On 2/18/25 at 9a.m, 2p.m. R4's physician order sheet shows orders for hydrocodone/APAP tab, 5-325MG (milligrams) give 1 tablet orally every six hours as needed for pain related to chronic pulmonary disease, order start date 11/1/2024. On 3/14/25 at 10:39am V4 said control substance should be signed out on the medication administration record after administration of the medication. Facility policy dated 10/2014 denotes in-part accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administrated, the licensed nurse administering the medication immediately enters the following information on the accountability record and medication administration record (MAR): date and time of administration. (MAR and accountability record). Amount administered. (accountability record). Remaining quantity. (accountability record). Initials of the nurse administering the dose, completed after the medication is actually administered. (MAR, accountability record). 2. On 3/12/25 at 3:20pm during survey tour with assist from V4 (Director of Nursing) to observe the practice of counting control substance/narcotics, R5's control drug receipt/record/disposition form was observed to have documented discrepancy below date of 2/18/25.
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145781
145781
03/14/2025
Generations at Applewood
21020 Kostner Avenue Matteson, IL 60443
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
R5's control drug receipt record denotes Hydrocodone 5-325mg was signed out on 2/4/25 at 9a.m., 2/5/25 at 10p.m., 2/6/25 9a.m., and 10pm, 2/7/25 at 9am, 2/12/25 at 10p.m., 2/13/25 at 9p.m., 2/14/25 at 7p.m, 2/18/25 at 10a.m., 2/19/25 at 10a.m., 2/20/25 at 9am, 2/21/at 10p.m., 2/22/25 at 9a.m., 2/22/25 at 6 (cannot determine if pm or am), 2/23/25 at 9a.m., 2/24/25 at 10a.m. R5's Medication Administration Record dated February 2025 was reviewed, there is no documentation denoting that hydrocodone was administered to R5 on 2/4/25 at 9am, 2/5/25 at 10p.m, 2/6/25 at 9am, and 10pm, 2/7/25 at 9am, 2/12/25 at 10pm, 2/13/25 at 9pm, 2/14/25 at 7pm, 2/18/25 at 10a.m., 2/19/25 at 10a.m., 2/20/25 at 9a.m., 2/21/25 at 10p.m., 2/22/25 at 9a.m., 2/22/25 at 6 (cannot determine if pm or am), 2/23/25 at 9a.m., 2/24/25 at 10a.m. R5's physician order sheet shows and order for Norco oral tablet 5-325 mg (hydrocodone-acetaminophen) give 2 tablets by mouth 6 hours as needed for mod to severe pain, order date 1/27/25. R5's physician order sheet shows and order for Norco oral tablet 5-325 mg (hydrocodone-acetaminophen) give 1 tablet by mouth 6 hours as needed for mild pain, order date 1/27/2025. On 3/14/25 at 9:44am R5 observed sitting in her wheelchair in her room, R5 observed alert to person, place and situation. R5 said her pain medication is scheduled as needed. R5 said she did not request or ask to take Norco multiple times in February. On 3/14/25 at 10:39am V4 said control substance should be signed out on the medication administration record after administration of the medication.
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