Failure to Administer Medications as Ordered Due to Unapproved Substitution
Penalty
Summary
The facility failed to administer medications as ordered for a resident with diagnoses including bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. The resident had a physician's order for Preservision AREDS 2 Soft gel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, interviews and observations revealed that the facility was actually administering Ocuvite instead of Preservision for an extended period. Staff, including LPNs and the DON, acknowledged that due to pharmacy and insurance issues, they substituted Ocuvite for Preservision without a physician's order to do so, and continued to document that Preservision was given. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that no refills for Preservision had been provided since late April. The resident reported the issue to multiple staff members and administration, but the substitution continued until the resident contacted the State Survey Agency. The care plan did not address the resident's diagnosis of macular degeneration, and staff were unclear about how long the incorrect medication had been administered. The facility's policy requires medications to be administered as ordered by the physician, but this was not followed in this case, as staff substituted a different supplement and documented administration of the original ordered medication.