Failure to Ensure Availability of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the availability of prescribed medications for a resident, identified as R244. The resident was admitted with chronic obstructive pulmonary disease, spinal stenosis, and chronic pain syndrome. Physician's orders indicated the resident was to receive oxycodone, methocarbamol, and ketorolac tromethamine for pain management. However, the Medication Administration Record (MAR) showed no documentation of oxycodone being provided on the day of admission, and methocarbamol was noted as on order from the pharmacy. The resident's pain levels were consistently high, ranging from 7 to 10 on a scale of 0 to 10, indicating severe pain. The facility's policy, "Pharmacy Services Overview," required the accurate and safe provision of pharmaceutical services, including routine and emergency medications. Despite this, the facility's automated medication dispensing machine inventory included the necessary medications, but they were not administered as prescribed. The Director of Nursing was informed of the failure to ensure the availability of prescribed medications for the resident, highlighting a deficiency in the facility's pharmacy services.
Plan Of Correction
Immediate Intervention: Immediate education for all nurses was given on medicating residents for pain and discomfort when pain is assessed. Education provided to all nurses by DON on medication availability in pyxis and process of obtaining new scripts. How to Identify residents who can be affected: All residents can potentially be affected. Prevention of further occurrence: Education for medicating for pain and discomfort along with medication availability in pyxis and process of obtaining new scripts will be done in orientation. Corrective Action to be monitored: DON/designee will audit documented pain scale against pain medications administered of 5 residents on each unit daily for five days, then weekly for three weeks, then monthly for three months. QA Program: Performance improvement plan using Plan do Study Act and root cause analysis for proper medication administration for PRN pain medication administration and availability of routine medications to be presented monthly at QAPI.