Discontinued Medication Not Removed, Resulting in Continued Administration
Penalty
Summary
A deficiency occurred when a discontinued medication, mupirocin ointment, was not removed from a treatment cart after the physician's order to discontinue it. Despite the order being discontinued, the ointment remained accessible in the cart, and a Licensed Vocational Nurse (LVN) continued to administer it to a resident during wound care. The LVN stated that she routinely applied the mupirocin to the resident's pressure injury, unaware that the order had been discontinued, as the medication was still present in the cart. The resident involved had a history of neurocognitive disorder with Lewy bodies and a stage two pressure injury on the sacral region. The resident was dependent on staff for all activities of daily living and was rarely able to communicate or understand others. The care plan for the resident included specific wound care instructions, and the physician's orders had clearly discontinued the use of mupirocin prior to the observed administrations. Interviews with nursing staff and the Director of Long Term Care confirmed that facility policy required discontinued medications to be removed from nursing stations immediately to prevent inadvertent administration. However, the discontinued mupirocin was not removed, resulting in its continued use on the resident. The failure to remove the medication from the cart and the subsequent administration of a discontinued drug constituted a breach of accepted medication storage and administration practices.