Failure to Administer Methadone as Prescribed by OTP Provider
Penalty
Summary
The facility failed to administer methadone in accordance with the dosage prescribed by the Opioid Treatment Program (OTP) provider for a resident being treated for opioid use disorder (OUD). The resident, who had a history of Hepatitis B and C, was managed by the OTP for methadone dosing, with care plans indicating that the dosage was to be determined at weekly outpatient appointments. Following a hospital visit for an opioid overdose, the hospital coordinated with the OTP to temporarily reduce the resident's methadone dose, with a plan to gradually return to the previous dosage as directed by the OTP. Despite clear orders from the OTP to increase the methadone dose back to 70mg daily, facility staff administered only 50mg daily for several days. This change was made based on a verbal order from a physician assistant at the facility, who cited recommendations from the resident's hepatology clinic to reduce or eliminate methadone use. There was no documentation that the OTP was consulted or that care was coordinated between the OTP provider and the hepatology team regarding this change in methadone dosing. The facility did not have a specific policy for residents utilizing an OTP and relied on the OTP provider's orders for methadone administration. However, the facility did not report the deviation from the OTP's prescribed dose until questioned by OTP staff about unused medication. Interviews with facility staff revealed confusion about which provider was responsible for managing methadone dosing for OUD, and there was no evidence of direct coordination between the involved medical providers regarding the resident's methadone regimen.