Failure to Administer Prescribed Methadone Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple diagnoses, including a left femur fracture with surgical repair and sepsis secondary to cellulitis, did not receive prescribed Methadone for opioid addiction. The resident had physician orders for Methadone 40 mg in the morning and 60 mg in the evening, but the Medication Administration Record (MAR) showed that both doses were missed on two consecutive days. Documentation indicated that the medication was unavailable as the reason for the missed doses. The Director of Nursing (DON) reported that the orders for Methadone were faxed to the substance abuse treatment center after it had closed, and despite multiple calls and messages, the medication did not arrive until the resident's third day at the facility. During this period, the resident exhibited behavioral changes, including verbal aggression, which led to a behavioral health evaluation. The facility was unable to provide evidence that the resident was kept free from significant medication errors, as the resident never received the prescribed Methadone during their stay.