Failure to Provide Ordered Pain Medication and Notify Physician
Penalty
Summary
The facility failed to provide pain medication as ordered for a resident with multiple complex medical conditions, including hemiplegia, aphasia, diabetes, COPD, vascular dementia, and chronic pain syndrome. The resident had a physician's order for a Butrans transdermal patch to be applied weekly for pain management. Review of the Medication Administration Record showed that the patch was not applied on two scheduled dates, and progress notes indicated the medication was unavailable at those times. Despite the unavailability of the ordered pain medication, there was no documentation that the physician was notified of this issue. The Director of Nursing confirmed that neither she nor the physician had been informed that the Butrans patch was not available. The pharmacy did not receive the prescription until several weeks after the initial order, as the physician was unaware of the situation. The resident's pain was managed by switching as-needed medication to a scheduled regimen during this period.