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F0759
D

Medication Administration Error Exceeds Acceptable Rate

Plainfield, Illinois Survey Completed on 04-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to physician's orders during medication administration, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the administration of medications to a resident (R15) by a nurse (V8). The nurse administered 10 ml of Lactulose Solution and 6 units of Novolog to the resident, despite the Medication Administration Record (MAR) indicating that the resident was supposed to receive 30 ml of Lactulose and 4 units of Novolog based on a blood sugar reading of 213 mg/dl. The Director of Nursing (V2) confirmed that medications must be administered according to physician orders, following the facility's policy and the 5 rights of medication administration, which include the right dose.

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