Failure to Ensure Timely Availability of Pain Medication
Penalty
Summary
A resident with a diagnosis of arthritis was admitted in June 2021 and was prescribed Norco to be administered every four hours for pain management. On January 30, 2025, the Medication Administration Record (MAR) showed that the resident did not receive Norco at four scheduled times throughout the day. Progress notes indicated that the medication was not available due to a delay in obtaining a new prescription, with staff waiting for delivery and notifying the physician of the missed dose. The physician was faxed for a new prescription later that morning, and the pharmacy confirmed that they did not receive the prescription until that day, after which it was filled. Staff interviews revealed that the process for obtaining new prescriptions involved notifying the nurse when a new order was needed, and the nurse would then request it from the physician. The Director of Nursing Services was unaware of the missed doses and unclear about why the prescription was not sent to the pharmacy following the physician's visit the previous day. The resident was noted to be cognitively intact at the time of the incident.