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F0684
D

Missed Prednisone Dose Due to Order Entry Error

La Grange, Illinois Survey Completed on 01-28-2026

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 administer a prescribed dose of Prednisone as ordered for one resident. The resident was admitted with multiple serious cardiopulmonary diagnoses, including malignant neoplasm of the lung, tachycardia, congestive heart failure, COPD, chronic respiratory failure, pulmonary embolism without acute cor pulmonale, and asthma. The EMR showed an order for Prednisone 30 mg once daily for three days starting on 1/18/2026 at 5 PM through 1/20/2026, followed by a new order for Prednisone 40 mg once daily for seven days starting on 1/21/2026 at 9 AM. The MAR documented that the resident received the 30 mg Prednisone doses on 1/18/2026 and 1/19/2026, but the 30 mg dose due on 1/20/2026 at 5 PM was not administered. The DON stated that when the pulmonary NP entered the new Prednisone 40 mg order to start on 1/21/2026, it accidentally cancelled the existing 30 mg dose scheduled for 5 PM on 1/20/2026, resulting in the missed dose, and both the DON and NP confirmed the resident should have received that 30 mg dose. The facility’s Medication Administration policy, reviewed in 4/2025, states that medications will be administered in a safe and timely manner and as prescribed.

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