Observations
Based on a review of client 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. The medication packaging identifies this as a single dose medication.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg SL film, 12 mg daily (1 1/2 films daily) for client # 6 on August 14 and September 11, 2012.
The physician prescribed Suboxone 8 mg/2 mg SL film, 12 mg daily (1 1/2 films daily) for client # 7 on the following dates: May 8, May 22, June 6, July 3, July 31, and August 21, 2012.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 8 mg/2 mg or 2 mg/.5 mg doses. A 12 mg dose requires the patient be given one 8 mg/2 mg dose and two 2 mg/.5 mg film doses.
The clinical supervisor was interviewed on September 11, 2012 and confirmed the findings.
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Plan of Correction
It shall be the responsibility of the Project Director to review the dosing protocol of the prescribed medication as a single dose medication with physician.
It shall be the responsibility of the Clinical Supervisor to notify the Project Director if physicians continue to prescribe in the manner cited. Project Director will follow-up with physician per occurrence. |