Improper Methadone Administration Due to Medication Order Misinterpretation
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of opioid abuse was prescribed methadone, with physician orders specifying a daily dose of 20 ml. Facility policy required medications to be administered according to written orders, with clarification sought if there was any uncertainty. However, an agency LPN misinterpreted the methadone orders and opened all six prefilled bottles of the resident’s weekly supply, rendering the medication unusable and necessitating its destruction. As a result, the resident was sent to the methadone clinic to receive the scheduled dose and returned with a replacement supply. Later the same day, the same LPN administered a second dose of methadone to the resident, despite the resident stating they had already received their dose at the clinic. Documentation confirmed that the LPN signed out and administered the additional dose. The LPN reported confusion regarding the physician’s order and difficulty reading the medication labels, which contributed to the error. Other staff confirmed the sequence of events, including the destruction of the original supply and the administration of the extra dose. The incident led to the revocation of the facility’s certification for weekly methadone take-outs, requiring the resident to visit the clinic daily for medication administration. Interviews with staff and the resident confirmed the administration of the extra dose and the confusion surrounding the medication orders and labeling. The resident did not experience a change from baseline after receiving the second dose, as observed by a respiratory therapist who provided a breathing treatment later that day.