Medication Administration Errors Result in Unnecessary Drug Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, as evidenced by medication administration errors affecting two residents. One resident with multiple diagnoses, including anxiety disorder and moderate cognitive deficit, was prescribed Lorazepam 0.25 mg twice daily for anxiety and Lorazepam 0.5 mg as needed. However, the resident was repeatedly administered Lorazepam 0.5 mg instead of the prescribed 0.25 mg dose on multiple occasions, with no evidence that the higher dose was given as an as-needed medication. Documentation showed that staff were signing off on the administration of the incorrect dose, contrary to the physician's orders. Another resident with a history of chronic pain and multiple comorbidities was prescribed Oxycodone 5 mg every six hours for pain and Hydromorphone 2 mg as needed for severe pain. The resident was administered an extra dose of Oxycodone 5 mg without a physician's order, and there was no documentation in the medical record or medication administration record (MAR) to support the administration of this extra dose. The incident was discovered during a narcotic shift count, but the error was not documented in the resident's records. Review of facility policy indicated that medications are to be administered as prescribed, with staff required to verify the right resident, medication, dosage, time, and method before administration. Despite these policies, the facility did not ensure adherence to medication orders, resulting in residents receiving unnecessary or incorrect doses of medication.