Failure to Provide Ordered Nicotine Lozenges for Resident with Nicotine Dependence
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of nicotine dependence and traumatic brain injury received physician-ordered nicotine lozenges to address nicotine cravings. The resident had an active order for 2 mg nicotine lozenges to be given by mouth every hour as needed, but the medication administration record showed that from the beginning to the end of the month, no doses were administered. During interviews and observations, the resident expressed a desire for cigarettes, and staff confirmed that the nicotine lozenges were not available and had never been administered, despite the order being present in the system. Multiple staff members, including an LPN, the unit manager, the DON, and the administrator, were unaware that the prescribed nicotine lozenges were not available or being given. The facility's policy on medication errors did not specifically address the unavailability of physician-ordered medications as a medication error. The lack of access to the ordered medication was identified through record review, staff interviews, and direct observation of the resident's requests and staff responses.