Failure to Administer Medications as Prescribed and Inaccurate Emergency Kit Labeling
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed and used appropriately to meet the needs of the residents. Specifically, a resident with schizophrenia was prescribed two long-acting injectable antipsychotic medications, Invega Sustenna and Haldol Decanoate, with orders for Invega Sustenna to be administered every 28 days. However, the medication administration record showed that Invega Sustenna was given earlier than prescribed: one dose was administered 21 days after the previous dose, and another was given 22 days after the prior dose. Interviews with the pharmacist, DON, and Medical Director confirmed that the medication was administered sooner than recommended by both the physician's order and the manufacturer's prescribing information. There was no physician order to alter the dosing interval, and no clinical evidence supported the practice of staggering the two antipsychotics two weeks apart. Additionally, during an inspection of the Emergency Kits, it was observed that the expiration date written on the outside of the Oral Emergency Kit did not match the actual expiration date of the medication inside. The kit was labeled with an expiration date of July, but it contained doxycycline tablets that expired in June. This discrepancy was confirmed by a licensed vocational nurse, who acknowledged that the expiration date on the outside of the kit was not correct. The facility's policies required medications and treatments to be administered as prescribed and for Emergency Kits to be inventoried monthly, with the earliest expiring medication's date noted on the outside of the kit. These policies were not followed, resulting in the administration of medication outside the prescribed schedule and inaccurate labeling of emergency medication expiration dates.