Failure to Administer Correct Dose of Buprenorphine
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a pathological fracture, malignant neoplasm of the esophagus, and aftercare for joint replacement did not receive the correct dose of buprenorphine as ordered by the physician. The physician's order specified that the resident should receive 1mg (half of a 2mg tablet) sublingually three times a day. However, documentation and medication card review revealed that on six separate occasions, the resident was administered a whole 2mg tablet instead of the prescribed half tablet. The medication card was bubble packed with 2mg tablets, and nursing staff were responsible for splitting the tablets to achieve the correct dose. Interviews with an LPN and the acting DON confirmed that the medication sign-out sheet documented the administration of whole tablets rather than half tablets, contrary to the physician's order and facility policy. The facility's policy required nursing staff to follow the five rights of medication administration and to triple check these rights during the process. The failure to administer the correct dose and to document it accurately led to a significant medication error for the resident.