Failure to Administer Methadone per Physician Order and Incomplete Error Reporting
Penalty
Summary
The facility failed to follow physician's orders and standards of practice regarding the administration of methadone to a resident with multiple diagnoses, including chronic pain, heart disease, and mental health conditions. After a recent fall, the resident's methadone dosage was reduced by physician order, but two nurses continued to administer the previous, higher dosage on multiple occasions. Documentation showed that the incorrect dosage was given on at least five separate dates, and there was uncertainty about whether a double dose was administered on one of those days. The medication administration records and narcotic logs confirmed these errors. The Director of Nursing (DON) was only aware of some of the medication errors and did not initiate an incident investigation until several days after the errors were reported, coinciding with the surveyor's presence at the facility. The DON was unaware of the full extent of the errors until the surveyor's review of the narcotic log. Additionally, not all staff involved in the errors received in-service education or counseling regarding medication administration errors, and one nurse denied making any mistakes despite documentation to the contrary. Further review revealed that medication errors were not documented in the resident's progress notes, and there was no evidence that the physician was notified of the errors. The facility's medication error policy provided to the surveyor was incomplete and did not emphasize the importance of physician notification. The medication administration policy required medications to be given as prescribed and errors to be documented and reviewed, but these procedures were not followed in this case.