Failure to Administer Controlled Medications per Provider Orders
Penalty
Summary
A deficiency was identified in the administration of controlled medications for one of three residents reviewed for medication administration. The resident, who had diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, and end stage renal disease, required total assistance with activities of daily living and was noted to have refused medications at times. On one occasion, a physician's order directed the application of two 50 microgram/hour Fentanyl patches every three days for chronic pain. Documentation inconsistencies were found: the Medication Administration Record (MAR) indicated two patches were administered at 8:00 AM, while the Controlled Substance Distribution Record (CSRD) only documented one patch given at 12:00 PM. The assigned LPN could not confirm whether the correct dose was administered at the correct time. The Director of Nursing (DON) confirmed that the patches should have been administered as ordered and that the five medication rights were not followed. In a separate incident, a physician's order for a 100 microgram/hour Fentanyl patch was received at 7:45 PM, but the CSRD showed the patch was administered at 3:00 PM, several hours before the order was obtained. The DON acknowledged that the medication was given prior to receiving the provider's order and reiterated the importance of following the five medication rights, including administering medications at the correct time. Facility policy required staff to follow written provider instructions and document medication administration at the time it occurred, which was not adhered to in these cases.