Failure to Provide Ordered Methadone for Three Consecutive Days
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered methadone for a resident for three consecutive days, despite having accepted the resident for admission with a care plan and physician orders that included daily methadone for opioid dependence and pain management. The resident was admitted with diagnoses including other psychoactive substance abuse and surgical aftercare needs, and was documented as alert and oriented x4 on admission. Physician orders and the care plan specified methadone concentrate 135 mg orally once daily, along with hydromorphone and oxycodone for breakthrough and PRN pain. The medication administration record showed that methadone was not administered on three consecutive days and was marked as not available on each of those days. The facility’s policy stated that it would admit only residents whose needs could be met and that if a non‑contract pharmacy could not provide ordered medications, the provider pharmacy could be contacted to supply them. During interviews, an LN reported that the facility did not administer the resident’s methadone because it was not available for three days and acknowledged that, on admission, the facility should have ensured it could meet the resident’s need for methadone. The LN stated the resident became upset and agitated due to not receiving the medication, threw water at a staff member, called 911, and left the facility against medical advice. Progress notes indicated the LN attempted to contact the methadone clinic and arrange for transport to obtain the medication, but the facility did not have transportation available for the resident to pick up the methadone. The DON confirmed that when the facility accepts a resident, it agrees to meet and provide the resident’s needs. The facility’s failure to secure and administer the ordered methadone as required resulted in the resident not receiving the medication for three consecutive days and experiencing distress.
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