Failure to Provide Prescribed Dose of Haloperidol Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to ensure that pharmacy services were maintained for one resident when the prescribed dose of haloperidol was not available for administration as ordered by the physician. Observation of medication administration revealed that the available haloperidol tablets were 5 mg, while the physician's order required 0.5 tablet (2.5 mg) to be given once daily. The nurse identified the discrepancy between the ordered dose and the available medication in the blister pack and did not administer the medication without clarification. The order for the new dosage had been changed the previous day, but the correct dose had not yet been delivered from the pharmacy at the time of the scheduled administration. Review of the resident's Medication Administration Record confirmed the order for haloperidol 5 mg, with instructions to give 0.5 tablet. The DON stated that the expectation was for the physician to sign the order promptly so the pharmacy could fill the prescription, but the medication dose was not available for the morning administration. The facility's policies required that the right dose be administered and that residents have a sufficient supply of their prescribed medications at all times. The failure to have the correct medication dose available resulted in a disruption of the resident's treatment plan.