Failure to Timely Obtain and Administer Prescribed Pain Medication
Penalty
Summary
A deficiency occurred when the facility failed to take timely and appropriate action to obtain and administer a prescribed medication for a resident. The facility's policies required that medications be administered safely and promptly as prescribed, and that medications be received from the pharmacy in a timely manner. Despite these policies, a resident who returned from the hospital with an order for morphine for pain and dyspnea did not receive the medication as needed upon readmission. The resident, who had diagnoses including palliative care, hypertension, and dementia, was documented as having significant pain and respiratory distress upon return to the facility. Nursing documentation indicated that the resident was non-responsive, had agonal breathing, and had received morphine prior to leaving the hospital. Pain assessments conducted after readmission showed observable signs of pain, including labored breathing and facial grimacing, with pain scores indicating moderate pain on two separate occasions. Despite the physician's order for morphine to be given as needed, the medication was not administered until the following morning, several hours after the resident's return. Staff interviews revealed that delays in obtaining a pull code for the controlled medication from the dispensing unit contributed to the delay, as the process required communication between the physician and pharmacist. The DON confirmed that the medication was not available or administered as ordered, despite documented pain and the resident's need for comfort measures.
Plan Of Correction
1) R1 received medication. 2) Director of nursing or designee audited current new residents admitted within the last 30 days with controlled substance orders to ensure no delay in medication administration and medication availability. 3) Director of nursing or designee educated Registered Nurses to receive pull code for controlled substances upon admission of new residents with narcotics. 4) Director of nursing or designee will audit new controlled substance orders for availability by either receiving pull code from emergency kit, having pharmacy perform stat run or utilizing a local back-up pharmacy to obtain medications, weekly for 2 weeks and then monthly until compliance is met. Results of audits will be reviewed in QAPI each month until compliance is met.