Failure to Ensure Timely Availability of Physician-Ordered Fentanyl Patch
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with chronic pain syndrome and other bone disorders by not ensuring the timely availability of a physician-ordered Fentanyl patch. Upon admission, the resident had a Fentanyl patch in place, but it was removed when it expired, and a replacement was not available due to delays in ordering the medication. The admitting nurse did not follow up with the physician to obtain the required triplicate order for the Fentanyl patch, and the nurse practitioner clarified that only the physician could order this medication. As a result, the resident went without the prescribed Fentanyl patch for an extended period, during which time she reported severe neck pain related to her medical condition. Documentation in the electronic medical record and medication administration record confirmed the gap in Fentanyl administration, with nursing notes indicating the medication was not available and was pending delivery from the pharmacy. Interviews with nursing staff and the director of nursing revealed a lack of clarity and training regarding the process for ordering controlled substances, specifically the need for physician involvement and timely follow-up to ensure medication availability. The facility's medication ordering policy did not address timelines or procedures for ordering narcotics, contributing to the delay in the resident receiving her prescribed pain management.