Failure to Provide Prescribed Pain Medication Due to Unavailability
Penalty
Summary
A resident with multiple complex medical conditions, including lumbar radiculopathy, open lumbar fracture, and chronic pain, was admitted with an order for Oxycodone-Acetaminophen 10-325 mg to be administered every 8 hours as needed for pain. Review of the medication administration records showed that the resident received this medication regularly in March, but it was not administered from April 1 through April 3. The controlled drug record confirmed that the medication was not available during this period. The resident's care plan specified that analgesia should be administered as ordered and that staff should anticipate and respond immediately to complaints of pain. During the period when the medication was unavailable, the resident expressed agitation and distress due to unrelieved pain, as documented in nurse's notes and confirmed in interviews with both the resident and staff. The nurse offered alternative pain relief options, such as Tylenol and ibuprofen, which the resident refused, and attempted non-pharmacological interventions without success. Both the DON and a corporate RN confirmed the unavailability of the prescribed pain medication for several days, resulting in the resident not receiving pain management in accordance with professional standards, the care plan, or the resident's preferences.