F0760

D

Missed Suboxone Doses Due to Untimely Reordering and Unavailability

Clearlake, California Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Suboxone for opioid dependence was not available and not administered as ordered. The resident was admitted with a diagnosis of substance dependence and had no documented memory impairment. A physician’s order dated 2/4/26 directed Suboxone sublingual film 8-2 mg, one film three times daily for opioid dependence. Review of the medication administration record for 2/26 showed that the resident did not receive Suboxone on three occasions: one evening dose on 2/23/26 and two doses on 2/24/26, with the MAR coded as “other/see Nurse Notes.” Progress notes documented that on 2/23/26 the Suboxone was pending pharmacy delivery, and on 2/24/26 it was not given and was unavailable due to the order pending the physician’s signature, and later still pending delivery.

During interview, the resident reported not receiving Suboxone for a week, stated he did not know why, and reported experiencing shaking and anxiety, noting he was a recovering heroin addict. The ADON, upon review of the MAR and progress notes, confirmed the three missed doses and that the medication had not been available for administration, and stated it was her expectation that medications be ordered timely and available so doses were not missed. She further agreed that, given the resident’s use of Suboxone for opioid dependence and his complaints of anxiety and shakiness due to missed doses, this constituted a significant medication error. Facility policies on Medication Reordering and Medication Errors stated that the facility would provide medications in a timely manner to meet each resident’s needs and ensure residents receive care in an environment free of significant medication errors.