Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including chronic pain and chronic opiate therapy, did not receive scheduled pain medication as ordered. The resident was admitted with orders for scheduled and as-needed oxycodone and tramadol. On the day following admission, the scheduled oxycodone doses were not administered because the nurse on duty, who was new to the facility, was unaware that the medication was available in the emergency controlled medication kit. The nurse did not contact the pharmacy, provider, or other staff to resolve the issue and did not document administration of as-needed tramadol, which she later stated she had given. The resident reported severe pain, stating her pain level exceeded 10 and caused her to cry and almost scream. Nursing staff and a nursing assistant confirmed the resident was in pain and that her medication had not arrived from the pharmacy. Documentation showed that scheduled oxycodone doses were marked as unavailable due to waiting on pharmacy delivery, despite the medication being present in the emergency kit. The nurse did not follow up with the on-call provider or pharmacy and did not seek assistance from other nurses or the DON regarding the missing medication. Interviews with facility leadership and other clinical staff revealed that the emergency controlled medication kit was fully stocked and contained the ordered medication. The DON and Administrator stated that nurses were expected to utilize the emergency kit and seek help if medications were missing. The failure to administer the scheduled pain medication as ordered resulted in unmanaged pain for the resident, as directly observed and reported by staff and the resident herself.