CHICAGO RIDGE, IL - Federal inspectors cited Chicago Ridge Nursing Center after discovering that 34 residents on the facility's third floor went without their morning medications on Christmas Day 2024, including five residents who required critical seizure medications.
Medication Administration Failure on Holiday
On December 25, 2024, approximately 34 residents housed on the third floor of Chicago Ridge Nursing Center did not receive their scheduled morning medications due to insufficient nursing coverage. The facility's medication administration records documented that no medications from the "front cart" - which served rooms 301-311 and 326-334 - were distributed during the day shift.
The breakdown in care occurred when the facility scheduled only one Licensed Practical Nurse (LPN) to cover all 72 residents on the third floor during the Christmas Day morning shift, despite the standard practice of assigning two nurses per floor. When the sole nurse on duty refused to assume responsibility for administering medications to all residents, management failed to implement an adequate contingency plan.
According to inspection records, the on-duty nurse clearly communicated to the Director of Nursing that she would only provide medications to residents assigned to her regular medication cart, which covered approximately half the floor. "I did not accept keys for that cart or anything," the nurse stated during the investigation. "I came in and did my residents, passed medications, and did make sure everyone was safe and taken care of but did not pass medications for the other half of residents."
The Director of Nursing acknowledged being aware of the situation throughout the day but indicated she believed the nurse would cover the entire floor. "I was under the impression that [the nurse] was going to pass medications for the whole floor," the DON told investigators. This fundamental miscommunication left 34 residents without access to their prescribed medications for the entire morning shift.
Critical Seizure Medications Withheld
Among the most serious consequences of the staffing failure was the impact on residents requiring anti-seizure medications. Five residents on the third floor were prescribed various anticonvulsant medications that were not administered on Christmas morning, creating potentially dangerous gaps in therapeutic coverage.
Anti-seizure medications work by maintaining consistent blood levels to prevent seizure activity. When doses are missed, medication levels drop below the therapeutic threshold, significantly increasing seizure risk. Medications like Keppra (levetiracetam), Depakote (divalproex sodium), and Lacosamide require regular dosing schedules to remain effective. A single missed dose can destabilize seizure control that may have taken weeks or months to establish.
The inspection report documented specific instances where residents missed critical medications. One resident did not receive morning doses of both Divalproex Sodium 250 mg and Levetiracetam 750 mg, both prescribed twice daily for seizure management. Another resident missed doses of Keppra 1,250 mg and Lacosamide 100 mg. A third resident's Depakote 500 mg dose - prescribed three times daily - was not administered at either the 8:00 AM or noon scheduled times.
The medical implications of missed anticonvulsant medications extend beyond immediate seizure risk. Abrupt changes in medication levels can trigger breakthrough seizures even in residents with previously well-controlled epilepsy. Seizures in elderly nursing home residents carry additional risks including falls, fractures, aspiration, and potential status epilepticus - a life-threatening condition of prolonged seizure activity.
Residents with cognitive impairments face particular vulnerability when medication routines are disrupted. The inspection noted that affected residents included individuals with dementia diagnoses and moderate cognitive impairment, conditions that make self-advocacy difficult. These residents depend entirely on facility staff to ensure medication administration occurs as prescribed.
Breakdown in Communication and Oversight
The investigation revealed multiple system failures that contributed to the medication administration breakdown. The facility lacked a formal staffing policy and had no established holiday rotation protocol to ensure adequate coverage during periods when regular staff might be unavailable.
Documentation showed that nursing schedules consistently indicated two nurses per floor for day and evening shifts on all three floors. However, the Christmas Day schedule reflected only one nurse assigned to the third floor day shift - a deviation from standard practice that should have triggered immediate intervention from nursing leadership.
When asked about notification procedures, the on-duty nurse confirmed she did not contact physicians to inform them that their patients had not received prescribed medications. "I did not call the doctors for the residents that I did not pass medications to on 12/25/2024 and let them know that the residents did not get their medications," she stated. "I was not the nurse for that med cart. I did not accept keys for that cart. Management knew I was not passing medications on that cart."
The facility's contracted Nurse Practitioner similarly confirmed receiving no notification about the medication administration failure. "I did not get a call regarding Christmas Day or any residents not receiving their medications that morning," the provider told investigators.
This lack of communication prevented prescribing providers from assessing residents for potential adverse effects or implementing monitoring protocols. Standard medical practice requires that physicians be notified when significant medications are not administered so they can evaluate whether additional interventions are needed.
The facility administrator acknowledged the potential severity of the situation during the investigation. "It could have been not so good of turnout as a lot of residents are on seizure medications, psych medications, etc.," the administrator stated. "Thank God it wasn't."
Residents Report Impact
Residents themselves provided accounts of the medication administration failure during the investigation. One resident stated: "We always have a nurse on shift to give medications except on Christmas Eve or Christmas Day that morning I did not get my medications."
Another resident provided more detailed information about the timeline of events: "We did not have a nurse on the 3rd floor day of Christmas on day shift. So, we did not get medications for the day. Someone came up from another floor about 5:00 pm and gave medications then, just the evening medications."
This account indicates that affected residents went approximately nine hours without scheduled medications before receiving their evening doses. For time-sensitive medications prescribed at specific intervals, this delay disrupts therapeutic effectiveness and creates gaps in coverage.
One resident also reported ongoing medication supply issues beyond the Christmas Day incident. The resident indicated going four days without seizure medication due to what staff described as insurance-related delays in obtaining refills. Investigation revealed that while the facility had access to the medication through an automated dispensing system and the resident had brought a personal supply upon admission, neither backup option was utilized to ensure continuity of therapy.
Systematic Issues with Medication Management
The inspection findings point to broader concerns about the facility's pharmaceutical services and medication management systems. Federal regulations require nursing homes to provide pharmaceutical services sufficient to meet the needs of each resident and to ensure medications are administered as ordered by prescribing physicians.
The facility's own policy for administering medications establishes clear expectations: "Medications shall be administered in physicians written/verbal orders upon verification of the right medication, dose, route, time and positive identification of the residents identity." The policy designates the Director of Nursing as responsible for supervision and direction of all personnel involved in medication administration.
When medications are not administered as scheduled, the facility's policy requires specific follow-up procedures. Staff members who discover missed medications must investigate whether administration occurred, document late entries if medications were given but not recorded, or follow the "missed dose/medication error protocol" if medications were not administered. No evidence indicated these protocols were followed for the 34 residents affected on Christmas Day.
The inspection also revealed inconsistencies in nursing coverage on other dates. While most days showed appropriate staffing levels, documentation gaps and isolated instances of single-nurse coverage on other floors suggested the Christmas Day incident may reflect systemic challenges with staffing adequacy and contingency planning.
Additional Issues Identified
Beyond the primary medication administration failure, inspectors documented related concerns about the facility's operational systems:
Staffing Policy Absence: The facility administrator confirmed the facility had no written staffing policy establishing minimum nurse-to-resident ratios or coverage requirements. This lack of formal standards made it difficult to determine whether staffing levels met regulatory requirements.
Holiday Coverage Planning: The facility had not established a holiday rotation system or on-call protocols to ensure adequate coverage during periods when regular staff might be unavailable. The administrator indicated plans to develop such protocols following the incident.
Medication Availability: Documentation showed at least one instance where prescribed medication was unavailable for several days due to insurance-related delays, despite the facility having access to emergency supplies through automated dispensing systems.
Communication Protocols: The absence of notification to prescribing providers when significant medications were not administered indicated gaps in clinical communication systems that should ensure physicians remain informed about changes in their patients' care.
The inspection was conducted on January 2, 2025, in response to a complaint filed on December 25, 2024. Federal surveyors cited the facility for violations of nursing staffing requirements, pharmaceutical services standards, and medication error prevention regulations. All violations were classified at the "minimal harm or potential for actual harm" level, indicating that while no residents experienced documented adverse outcomes, the failures created substantial risk of negative health consequences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chicago Ridge Nursing Center from 2025-01-02 including all violations, facility responses, and corrective action plans.
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