Failure to Administer Ordered Medication Due to Unapproved Substitution
Penalty
Summary
The facility failed to ensure that medications were available and administered 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 Softgel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, the resident reported that she was receiving Ocuvite instead of Preservision for her macular degeneration, despite informing nursing staff, administration, the DON, and the ADON. Upon inspection, it was confirmed that Preservision was only obtained after the resident contacted the State Survey Agency, and the medication bottle was dated the same day as the surveyor's visit. Interviews with staff revealed that the pharmacy stopped sending Preservision, and staff substituted Ocuvite based on information from the pharmacy and direction from the DON, without a physician's order to change the medication. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that Preservision had not been refilled since the initial supply. Staff were unsure how long the resident had been receiving the incorrect medication, and the MARs continued to indicate that Preservision was administered, despite the substitution. The facility's policy requires medications to be administered according to physician orders and regulations, which was not followed in this case.