Multiple Medication Administration Errors with Antianxiety Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders and its own medication administration policy for two residents receiving antianxiety medications. One resident with type 2 diabetes, morbid obesity, depressive disorder, panic disorder, and anxiety had intact cognition and required setup assistance for activities of daily living. This resident had physician orders for clonazepam 1 mg every morning and 2 mg every night. Record review showed clonazepam was generally documented on the MAR as given twice daily in November, but the controlled narcotic count sheets revealed multiple missed and incorrect doses. The 1 mg morning dose was not administered on a specific date when the last available tablet had been given the prior evening, and a refill was pending. The 2 mg bedtime dose was not signed out as administered on several dates, and on another date the resident received two separate 1 mg doses at bedtime instead of the ordered 2 mg tablet. Additionally, the 2 mg clonazepam dose was signed out as administered in the morning on multiple dates, contrary to the bedtime order. The resident reported receiving clonazepam on one night but not at the correct dose and stated the facility did not have the ordered morning dose the following day while waiting for a new prescription. Another resident with chronic obstructive pulmonary disease, respiratory failure, and an anxiety disorder, and with impaired cognition, had an order for Xanax 1 mg by mouth three times daily for anxiety. The MAR for this resident showed Xanax as administered as ordered, but the controlled drug administration record documented administration at times and frequencies that did not match the three-times-daily order. On multiple dates, Xanax 1 mg was given four times in a day or at times inconsistent with the ordered schedule. In interviews, the DON confirmed that for both residents, clonazepam and Xanax were not administered as ordered and that multiple medication administration errors occurred. Review of the facility’s “Administration Procedures for all Medication” policy indicated staff were required to complete the five rights of medication administration, but the facility failed to follow this policy in these instances.
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