Failure to Provide Ordered Pain Medication Due to Refill and Communication Lapses
Penalty
Summary
The facility failed to ensure that pain-relieving medication was available and administered as ordered for a resident with chronic pain and multiple diagnoses, including osteoarthritis, malignant neoplasm of the bladder, and anxiety disorder. The resident was admitted with a seven-day supply of belbuca buccal film, prescribed for chronic pain, with no stop date on the order. After the initial supply was exhausted, the resident did not receive the medication for two consecutive days, despite being in constant pain as documented in the pain assessment and requiring ongoing pain management per the care plan. During this period, the resident reported a pain level of 10 out of 10 and was only given acetaminophen, which reduced the pain to 5 out of 10. Nursing documentation indicated that the belbuca buccal film was not available and that the facility was waiting for pharmacy delivery. However, interviews with the nurse practitioner and the facility's pharmacist revealed that staff did not notify the nurse practitioner of the need for a refill, nor did they contact the pharmacy to request the medication. The resident reported informing multiple nurses about the pain and the missing medication, but the issue persisted for two days. The facility's pain management policy required appropriate interventions to address pain, but the necessary medication was not obtained or administered as ordered.