Failure to Ensure Accurate Medication Dosage Verification
Penalty
Summary
A deficiency occurred when a resident with a history of unspecified seizures, opioid use disorder in remission, hypertension, and major depressive disorder was administered an incorrect dosage of Suboxone following re-admission from the hospital. The facility's pharmacy staff generated a label for Suboxone 2mg as ordered, but the technician mistakenly labeled an 8mg package instead. This error was not detected during the pharmacist's verification process, nor was it identified by the receiving nurse who signed off on the medication. The resident was on hospital leave at the time the medication was received, and the incorrect medication was stored until the resident's return, at which point the incorrect dose was administered. Multiple staff, including the pharmacist and nurses, failed to verify the correct dosage before administration, resulting in the resident receiving a higher dose than prescribed. The facility's policies required narcotic counts and verification at shift changes, as well as proper pharmacy verification procedures, but these were not followed. The error was discovered only after the resident had already received the increased dose, prompting further evaluation. The report confirms that the resident did not experience adverse effects from the increased dose.