Failure to Adhere to Medication Administration Standards and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by administering medication prescribed for one resident to another and inaccurately documenting the transfer and administration of a controlled substance. Specifically, a resident on hospice care with a diagnosis of malignant neoplasm of the bronchus and secondary malignant neoplasm of the digestive organs was ordered Lorazepam Intensol for restlessness and anxiety. Due to a pharmacy backorder, nursing staff borrowed an unused bottle of Lorazepam Intensol prescribed for another resident and administered it to the hospice resident. Documentation in the narcotic count book was inaccurate, as 15 ml was recorded as transferred when in fact 30 ml was moved, and there was no clear evidence of the medication being properly transferred or received from the pharmacy. Facility policy explicitly prohibits administering medications supplied for one resident to another. The medication administration record confirmed that the hospice resident received doses from the borrowed medication on multiple occasions. Staff interviews revealed acknowledgment of the errors, including the incorrect route of administration entered in the physician's order and the improper borrowing and documentation of the medication. The staff educator confirmed that the medication should not have been borrowed and that the narcotic documentation was incomplete and inaccurate.