Failure to Verify and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medication doses were properly verified prior to administration and did not administer available medications as ordered by physicians for two residents. In the first instance, a resident with a diagnosis of depression and mild cognitive impairment was prescribed Wellbutrin XL 150 mg to be taken in the morning. During a medication pass, an RN administered a pill labeled as bupropion ER XL without a dosage indicated on the packaging. The RN did not verify the dosage before administration, relying solely on pill recognition, and did not contact the pharmacy to confirm the correct dosage or report the labeling issue. In the second case, a resident admitted with multiple pain-related diagnoses was prescribed Percocet, Tylenol, and gabapentin for pain management. Although both Percocet and gabapentin were available in the facility's Cubex machine, the resident was only given Tylenol for severe pain, as the nurse did not access the Cubex for the other medications or contact the pharmacy for authorization. The resident's pain was not effectively managed, and the prescribed medications were not administered as ordered, despite being available on-site. Interviews with pharmacy staff, nursing staff, and facility leadership confirmed that the required medications were present in the Cubex machine and that staff were aware of the procedures to access them. Facility policies required medications to be administered as prescribed and for staff to verify medication details prior to administration, but these procedures were not followed in the cases reviewed.