Unordered Administration of Controlled Substance Due to Medication Verification Failures
Penalty
Summary
The facility failed to prevent multiple significant medication errors involving the administration of a controlled substance without a valid physician's order. A resident with a diagnosis of malignant neoplasm of the bone and a pathological fracture of the left humerus was admitted with a prescription for Percocet from the hospital, but this order was discontinued by the facility nurse practitioner upon admission. Despite this, the resident's bottle of Percocet was kept in the controlled drug storage drawer, and the medication was administered to the resident on nine separate occasions by five different nurses, without a corresponding physician's order or pharmacy approval. Interviews and record reviews revealed that the nurses did not verify the medication against the active physician's orders or the medication administration record (MAR) before administering Percocet. One nurse admitted to not knowing that Percocet was different from oxycodone and did not check the medication against the order. The controlled drug record (CDR) used to document the administration of Percocet was handwritten and lacked essential labeling information, which contributed to repeated errors. The MAR did not include an administration history or directions for the Percocet that was given. The facility's policy required verification of a physician's order and confirmation of the medication name and dose with the MAR prior to administration, especially for narcotics. However, these procedures were not followed, resulting in the administration of a controlled substance without proper authorization or documentation. The errors were discovered during a routine narcotic count, which revealed discrepancies in the controlled drug record and missing pills from the resident's supply.