Observations
Based on a review of patient records, the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be halved, quartered and cut into eighths in three of seven patient records. The medication packaging identifies this as a single dose medication.The findings include:The physician prescribed Suboxone 8 mg/2 mg SL film, (1/2 film twice a day) for patient # 1 on March 16, 2015. The physician prescribed Suboxone 8 mg/2 mg SL film, (1/2 film QD) for patient # 4 on July 18, 2015. The physician prescribed Suboxone 8 mg/2 mg SL film, (1/2 film QD) for patient # 9 on January 12, 2015.Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During our yearly inspection NHS Susquehanna Center received a citation due to the facility's physician failing to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be halved, quartered and cut into eighths in three of seven patient records. The medication packaging identifies this as a single dose medication. The facility?s program director will review the dosing information for Suboxone with both facility?s physicians to ensure that they are in compliance with the Suboxone film being a single dose medication. This will be documented on a sign off sheet for both physicians due by 11/24/15. Moving forward, all patients receiving Suboxone film will receive a dose review by the prescribing physician. If the patient?s dosage currently requires them to cutting the film in smaller doses the prescribing physician will change the dosage/mg to be in compliance with the medication. The site director will complete an ongoing monitoring of how Suboxone Film is being dosed through auditing the patients? medication flow sheets. |