Failure to Ensure Accurate Medication Dispensing and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents. One resident, who was nonverbal, bedridden, and dependent on staff for all care needs, tested positive for barbiturates during a hospital visit. Review of her medical record revealed no current prescription for barbiturates, and her medication orders did not include any drugs that would result in a positive barbiturate test. The resident had a history of Alzheimer's disease, dementia with behavioral disturbances, dysphagia, and muscle weakness, and required total assistance for all activities of daily living. Staff observed a change in her usual behavior, leading to her being sent to the hospital, where the positive barbiturate result was discovered. Another resident, who was cognitively intact and independent in most daily activities, was prescribed Primidone, a medication that metabolizes as a barbiturate. Review of the medication administration record (MAR) showed that this resident did not receive his prescribed Primidone on two consecutive days. The medication cart was organized with each resident's medications behind their respective name cards, and both residents' medications, including Primidone, were stored next to each other. An LVN reported believing she had administered the medication but forgot to sign off, while another nurse could not be interviewed regarding the missed dose. Interviews with staff and the DON confirmed that only the second resident was prescribed Primidone, and there were no barbiturates in the facility. The DON and medical director acknowledged that Primidone could result in a positive barbiturate test. The proximity of the medications in the cart and the lack of documentation for the administration of Primidone contributed to the possibility of a medication error, either through omission or unauthorized administration.