F0760

J

Significant Methadone Overdose Due to Failure to Follow Medication Administration Rights

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident receiving Methadone for substance use disorder was administered the medication according to the physician’s order, resulting in a significant medication error. The resident had diagnoses including opioid dependence, adjustment disorder, anxiety disorder, COPD, and a deviated nasal septum, and was care planned as being at increased risk for pain and using Methadone for treatment. A physician’s order directed that Methadone concentrate 10 mg/mL be given at a dose of 10 mg orally once daily for Methadone maintenance therapy.

On the day of the incident, the RN responsible for medication administration opened the locked Methadone cart and removed Methadone bottles and chain-of-custody records for two residents at the same time, placing both bottles on top of the medication cart. With the cart positioned in the doorway of one resident’s room, the RN asked the resident to state their name and Methadone dose and verified the bottle and record, but then turned and picked up a Methadone bottle without confirming it was the correct one before handing it to the resident. The resident noted that the amount of liquid in the bottle was unusually large compared to their usual dose and questioned the RN, who initially affirmed it was correct. After the resident consumed the Methadone, the RN checked the bottle and discovered that the resident had been given another resident’s Methadone, which was a 120 mg dose instead of the prescribed 10 mg.

The resident’s clinical record and hospital documentation confirmed that the resident received 120 mg of Methadone rather than the ordered 10 mg, constituting an 1100% higher dose. The resident was transferred to the hospital, where the discharge summary documented admission for accidental Methadone overdose, an ICU stay, and treatment with a Narcan drip, which was later weaned before the resident was restarted on Methadone 10 mg daily and discharged back to the facility. Interviews with the resident, the RN, the APRN, and the DON, along with review of the facility’s Medication Administration policy, showed that the RN did not follow the six rights of medication administration, including verifying the right resident and right dose at the bedside, and improperly removed and handled two residents’ Methadone bottles simultaneously, leading to the significant medication error.