Failure to Ensure Accurate Medication Administration and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals as required by regulation. For one resident, there was a failure to follow up on the Medication Regimen Review (MRR) recommendations made by the pharmacist. The MRR had identified a discrepancy between the physician's order for hydrocodone-acetaminophen for moderate pain and the medication blister pack and reconciliation count sheet, which were labeled for severe pain. The nursing staff did not ensure that the medication order on the pain assessment flow sheet matched the reconciliation sheet, and the updated order was not communicated to the pharmacy. As a result, the resident was at risk of not receiving the appropriate medication for pain management. Additionally, the facility did not communicate a new medication order to the pharmacy for the same resident. When the parameters of the hydrocodone-acetaminophen order were changed, the updated order was not faxed to the pharmacy as required. Nursing staff acknowledged that it was their responsibility to ensure the medication blister pack matched the current physician order, but this was not done. The Director of Nursing confirmed that discrepancies between the order and the medication packaging could lead to medication errors and that the resident could be under or over medicated. For another resident, the facility failed to follow physician orders regarding the administration and removal of a Lidoderm (lidocaine) patch. The order specified that the patch should be applied in the morning and removed at bedtime, but documentation did not indicate that the patch was removed as ordered. The resident reported that the patch had not been removed for two days, and observation confirmed the patch was still in place without a date. Nursing staff and supervisors acknowledged that the patch should be on for 12 hours and off for 12 hours, and that leaving it on longer could cause skin irritation. The facility's policy required medications to be administered as prescribed, including adherence to required time frames, but this was not followed in this case.
Plan Of Correction
F-tag 755 I: Corrective Action for residents found to have been affected: • Resident 21 was no longer in the facility as of 05/22/2025. • Resident 1 was reassessed by RN on duty for any negative effects due to not administering medication as per physician's order. Resident remains stable at this time. • Clarification of Resident 1 medication was made by RN with physician on 5/18/2025. Resident 1's order for hydrocodone-acetaminophen was communicated and clarified by the licensed nurse to the pharmacy and delivered on 05/18/2025. • Resident 1's MRR was communicated to attending physician on 5/17/2025 by the RN and on 5/18/2025 an order clarification was given by the attending physician. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • The facility's Medication Regimen Review (MRR) for the current residents was requested from Pharmacy by the DON on 05/21/2025. Recommendations and follow-up were completed on 05/28/2025 by the DON. • The RN performed an audit for residents with lidocaine patch orders on 5/17/2025 to ensure orders are followed per the physician orders. • The DON/designee conducted a facility-wide audit on 5/28/2025 for all narcotic medications orders for accuracy. No further findings. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication to the residents. • The Medical Records Director/designee will conduct a daily audit of the MRRs for the new admissions and the DON to follow-up for the monthly MRR provided by the pharmacist consultant. • The Medical Records Director/designee shall conduct a monthly audit that the Medication Regimen Review (MRR) pharmacy recommendations are completed and will report the findings to the DON for follow-up. • The Medical Records Director/designee will conduct daily audits of residents' new physician's orders to ensure physician's orders are accurate and being followed. IV. Facility's plan to monitor corrective actions to achieve & sustain compliance; Integrate the POC to QA Process: • The DON/designee will report issues or trends from the weekly audits conducted for Lidocaine orders are followed per physician orders during the monthly QAA meeting x 3 months to ensure compliance. • The MRD/designee will report issues or trends from the weekly audits of new medication orders are communicated to the pharmacy and the Medication Regimen Review (MRR) are completed during the monthly QAA meeting x 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025