Failure to Administer Scheduled Pain Medication Due to EMDS Access Issues
Penalty
Summary
A deficiency occurred when a resident with a history of multiple back surgeries, diabetes mellitus, bipolar disorder, and acute on chronic pain did not receive two consecutive scheduled doses of hydromorphone, a narcotic pain medication, as ordered by their physician. The medication was to be administered every four hours for pain, but the 6:00 P.M. and 10:00 P.M. doses were missed. The omission was due to nursing staff being unable to access the facility's Emergency Medication Dispensing System (EMDS), which requires a security code for medication retrieval. On the evening in question, an agency nurse assigned to the resident did not have access to the EMDS. Another nurse attempted to assist but encountered an error code indicating insufficient medication, which locked the system. Only the DON or ADON had administrative access to override the EMDS, but neither was available on-site to resolve the issue. As a result, the resident's pain medication was not administered as scheduled. Interviews revealed that the pharmacy representative confirmed both the DON and ADON could override the EMDS and that alternative medications were available. The pharmacy also indicated that if the original order had been placed as a STAT order, the needed doses could have been delivered. The DON stated that staff are expected to order medications timely and to contact the pharmacy for assistance if access issues arise, but it was unclear if this protocol was followed during the incident.