Failure to Properly Administer Ordered Crushed Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Ingreeza. Facility policy on Medication Shortages/Unavailable Medications required staff to obtain medications from the pharmacy or alternate sources and to obtain alternate prescriber orders if medications were unavailable, and the resident’s care plan directed that pills be finely crushed. The resident, admitted with bipolar disorder, anxiety, and depression, had a physician’s order for 40 mg of Ingreeza once daily for drug-induced subacute dyskinesia and a separate order that medications be crushed. During a medication pass observation, an LPN prepared to administer the resident’s 40 mg Ingreeza capsule softened in pudding and failed to ensure that all medications were finely crushed, contrary to the resident’s care plan and physician order. The LPN did not open the capsule and sprinkle the contents into the pudding, and instead administered the capsule softened in pudding. In subsequent interviews, the LPN confirmed she failed to administer the Ingreeza as ordered, and the Assistant Director of Nursing confirmed that this was an inappropriate administration of the medication and constituted a significant medication error. The Nursing Home Administrator also confirmed that the facility failed to ensure residents were free of significant medication errors for this resident.
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