Failure to Provide and Accurately Document Ordered OTC Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered medication was available and accurately documented as administered for a resident. During a morning medication pass, an RN was unable to locate the ordered dextromethorphan tablets, which had been ordered from the pharmacy several days earlier. The DON later explained that dextromethorphan is an OTC medication that the facility, not the pharmacy, is responsible for providing, and that the floor nurse who entered the order should have received and reported a pharmacy message indicating the medication would not be delivered. The resident’s January MAR showed an order for dextromethorphan 15 mg at bedtime for 3 days for TBI-related mood instability, with doses signed out as given, and a second order for dextromethorphan 15 mg twice daily for the same indication, with only the first dose signed out as given and subsequent doses marked as not available. The facility’s medication ordering policy did not address procedures for obtaining OTC medications, and no additional pharmacy policies were provided.
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