Failure to Administer Ordered Narcotic Pain Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's disease, chronic pain syndrome, and systemic inflammatory response syndrome, did not receive narcotic pain medication as ordered. The resident's care plan included administration of pain medication as prescribed by the physician. However, a change in the fentanyl patch order from 12 mcg/hr to 25 mcg/hr was made, but the facility did not have the 25 mcg/hr patches available. As a result, the resident did not receive any fentanyl patch from 4/17/25 through 4/21/25. The electronic medication administration record (eMAR) reflected this gap, and staff noted the absence of the medication during this period. The Director of Nursing confirmed that the pharmacy had not delivered the required medication, and the Registered Nurse identified that the administration dates were incorrect in the electronic record, leading to the missed doses. The facility's policy requires medications to be administered according to physician orders, but this was not followed due to the unavailability of the prescribed medication and lack of timely communication with the medical provider to address the issue. The resident was observed to be non-interviewable due to confusion at the time of the survey.