Failure to Administer Ordered Controlled Medication and Improper Borrowing of Medication
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that controlled medications ordered for a resident were administered as prescribed. Specifically, the resident had a physician's order for Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for pain. However, due to the facility not having the resident's pain medication available, an LPN borrowed the same medication from another resident and administered it to the resident in need. This action was acknowledged by the LPN, who stated she knew it was not appropriate, and was confirmed by the Director of Nursing and RN Supervisor. The resident involved had multiple diagnoses, including COPD, Type II Diabetes Mellitus with neuropathy, severe dementia with agitation, opioid dependence, and anxiety disorder. The resident was cognitively intact and required some assistance with activities of daily living. The lack of medication availability was noted by staff over several days, and the improper administration of another resident's medication was observed and reported by staff and family members. The facility's policy required strict adherence to medication administration standards, including verifying the right resident and medication, which was not followed in this instance.