Failure to Ensure Timely Administration of Scheduled Narcotic Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs for a resident with multiple diagnoses, including atherosclerotic heart disease, dementia, chronic pain, and anxiety disorder. The resident had a physician's order for Tylenol-codeine 3 to be administered every 8 hours, but the medication was not given at two scheduled times due to it being unavailable. Documentation on the Medication Administration Record (MAR) indicated the medication was not administered at midnight for an unspecified reason and at 8:00 AM due to the drug being unavailable. Interviews with nursing staff revealed that the medication was not available in the facility because the pharmacy was closed and the refill had not been ordered in time. Staff indicated that narcotics required a provider to call in refills, and there was confusion about the use of the emergency kit (e-kit), with some staff believing it was tied to a specific pharmacy. The Director of Nursing (DON) clarified that the e-kit was available for any resident and that staff should have notified her or the provider about the missed dose. The DON also stated that medications should be ordered 5-7 days before running out, and that documentation of refill orders was inconsistent. The resident reported running out of Tylenol 3 earlier in the week and experienced pain related to chronic back and sciatic nerve issues. Staff interviews indicated that the resident did not display obvious signs of pain at the time the medication was missed, and alternative pain medication was available but not requested. The nurse practitioner (NP) was notified after the fact and expressed minimal concern, stating the resident had access to regular Tylenol and did not consider the situation an emergency. Facility policy required medications to be administered as ordered unless a provider specified otherwise.