Failure to Accurately Dispense, Administer, and Document PRN Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents reviewed for pharmacy services. For one resident, who had a history of opioid overdose and was discharged from the hospital with explicit orders not to receive opioid medications, a nurse administered hydrocodone/acetaminophen (Norco) despite these restrictions. Documentation was inconsistent, with the narcotic administration record indicating the medication was given, but the medication administration record and progress notes lacking corresponding entries. Interviews with nursing staff and administration confirmed that the hospital discharge orders were not properly followed, and the medication was not discontinued or clarified with the physician as required. For another resident, there were discrepancies between the narcotic administration record and the medication administration record regarding the administration of PRN pain medication. The narcotic log showed multiple instances of hydrocodone/acetaminophen being administered, but the medication administration record did not reflect these doses. Interviews with staff revealed that nurses were not consistently documenting PRN medication administration on both required records, which was acknowledged as a risk for medication errors, double dosing, or potential drug diversion. Facility policy required that all PRN medication orders specify the reason and frequency for use, and that administration be documented on the medication administration record, including symptoms prior to administration and results. The policy also required complete documentation in the nurse's notes or the designated area for PRN documentation. The failure to maintain accurate documentation and to verify current physician orders before administering medications resulted in medication errors and placed residents at risk for adverse outcomes.