Failure to Ensure Drug Regimen Was Free from Unnecessary Drugs and Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs and that medications were administered according to physician orders and facility policy. A review of records showed discrepancies between the hospital discharge prescription, physician orders, the medication administration record (MAR), and the medication monitoring/control record for Dilaudid, a narcotic pain medication. The resident was admitted with multiple diagnoses, including osteoarthritis, hypertension, diabetes, neurocognitive disorder with Lewy Bodies, and dementia. The resident was prescribed several medications, including Dilaudid, Flexeril, hydroxyzine, Buspar, Cymbalta, Celebrex, Abilify, Effexor, and Trazodone. The MAR and medication monitoring/control record showed inconsistent documentation of Dilaudid administration, with doses given without supporting documentation of pain or non-pharmacological interventions being attempted prior to administration, as required by the care plan and physician orders. Further review revealed that Dilaudid was administered multiple times without documentation of the resident experiencing pain, except for one instance. There was also no evidence that non-pharmacological interventions were attempted before administering the narcotic, and the MAR did not reflect all administrations recorded in the medication monitoring/control record. The facility’s policy required that medication orders be verified and that discrepancies be clarified with the physician, but this was not done. The DON confirmed that the order was incorrectly entered and that the discrepancies between the order, MAR, and controlled record were never clarified. Additionally, the resident received Dilaudid for zero out of ten pain on several occasions. The resident subsequently experienced increased lethargy and altered mental status, leading to hospitalization. Hospital records indicated a positive opioid screening and a diagnosis of acute metabolic encephalopathy likely due to narcotic pain medication use, with polypharmacy also suspected as a contributing factor. Several medications, including Dilaudid, were discontinued in the hospital, and the resident’s pain was managed with Tylenol. Interviews with facility staff confirmed the medication order entry error and lack of documentation for pain or non-pharmacological interventions prior to administration of Dilaudid.