Methadone Administered Without Physician Order
Penalty
Summary
A resident with diagnoses including long-term use of opiate analgesics and a wedge compression fracture of the first lumbar vertebra was admitted alert and oriented, requiring limited assistance with transfers and being independent with bed mobility. The Methadone Chain of Custody Record showed that this resident received Methadone concentrate 120 mg/mL from 2/5/26 through 2/24/26. However, the physician’s order for Methadone concentrate 120 mg/mL, 120 mg orally once daily for Methadone maintenance therapy, was not entered until 2/7/26, after the resident had already received doses on 2/5/26 and 2/6/26. The DON stated that medications should not be administered without a physician’s order and reported being unaware that the resident did not have a physician’s order for Methadone until 2/7/26. The DON also identified that the facility used the Methadone Chain of Custody Record as the Methadone administration record, but a physician’s order should have been entered into the electronic medical record. Facility policy for residents receiving Methadone for opioid addiction required that the attending physician and pharmacy be notified of the resident’s participation in the Methadone maintenance program and that an order be obtained for self-administration after a self-administration evaluation. The undated Medication Administration policy directed staff to follow the six rights of medication administration and to compare the medication source with the Medication Administration Record to verify the resident’s name, medication name, form, dose, route, and time.
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