Failure to Provide Prescribed Pain Medication Due to Lapses in Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with a history of left below-knee amputation, peripheral vascular disease, type 2 diabetes with hyperglycemia, and cellulitis. The resident had an active order for Acetaminophen-Codeine Tablet 300-30 mg to be administered every six hours for pain, but missed three doses due to the medication not being available. Nursing staff did not ensure the prescription was filled in a timely manner, and the resident was instead given Tylenol 500 mg without a corresponding order being entered into the electronic medical record. The resident reported being in pain and questioned the nurse about the medication provided, noting that the pill given did not match the usual appearance of his prescribed pain medication. Despite the resident's repeated inquiries, the nurse assured him it was the correct medication. The nurse later admitted to giving Tylenol 500 mg instead of the prescribed Acetaminophen-Codeine and signing off on the medication administration record for the wrong medication. The nurse also failed to notify supervisors or access the emergency medication supply system (cubex) when the prescribed medication was unavailable. Interviews with facility staff revealed that the process for reordering controlled medications required a new prescription from the prescriber, and that staff were trained to access emergency supplies or notify supervisors if medications were not available. However, in this instance, the nurse did not follow these procedures, resulting in the resident missing prescribed doses and receiving an unprescribed substitute medication. The incident was only brought to the attention of facility leadership after the resident filed a grievance.