Failure to Ensure Accurate Medication Administration and Dosage Verification
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and consumption of medications for a resident with multiple diagnoses, including metabolic encephalopathy, anxiety disorder, and acute kidney failure. Observations revealed that the resident had multiple medication cups and loose pills, including hydrocodone-acetaminophen and tamsulosin, left in his room and not consumed as intended. Nursing staff admitted to leaving medications at the bedside and not verifying that the resident had actually swallowed the medications, despite being trained to do so. The resident was cognitively intact and had a history of rejecting care, but staff did not consistently follow procedures to ensure medication administration was completed as required. Additionally, the facility failed to ensure the resident received the correct dosage of hydrocodone-acetaminophen as prescribed by the physician. The physician's order was for 10/325 mg, but the resident was administered 5/325 mg tablets on multiple occasions. This discrepancy occurred after a new prescription was filled by the pharmacy, and nursing staff did not verify the medication received against the physician's order. Multiple nurses administered the incorrect dosage, assuming the medication on hand was correct, and did not clarify the discrepancy with the physician or pharmacy. The error was only discovered after review and interviews with staff and pharmacy personnel. Interviews with nursing staff and administration confirmed that the facility's policy required verification of the right dose and observation of medication consumption, but these procedures were not followed. Staff acknowledged being aware of the resident's behaviors and the need for careful administration but failed to adhere to established protocols. The facility's Director of Nursing and Assistant Director of Nursing both stated that medications should not be left at the bedside and that the correct dosage must be verified before administration, but these expectations were not met in practice.