Failure to Administer Scheduled Pain Medication Due to Lapse in Medication Supply
Penalty
Summary
Resident #4, who was admitted with multiple diagnoses including a right ankle fracture, chronic pain syndrome, and various mental health disorders, was prescribed a combination opioid/acetaminophen pain medication to be administered four times daily. The resident was cognitively intact and had a care plan in place for pain management. On observation, the resident was found to be in visible discomfort, reporting severe pain and sweating, and stated that they had requested pain medication but were told none was available. Review of medication records showed that several scheduled doses were not administered as prescribed, with gaps in administration documented on the Medication Administration Record and the Controlled Substance Log. The last dose before the gap was given in the evening, and the next dose was not administered until over 24 hours later. The failure to provide the scheduled pain medication was due to the medication supply running out, as confirmed by the empty medication card and log. Staff interviews revealed confusion regarding the process for obtaining prior authorization (PA) for controlled substances, with nurses unsure of their responsibilities and the timing for reordering. The pharmacy confirmed that a PA was required and that the facility was responsible for obtaining it. The facility did not utilize the emergency medication box because it did not contain the correct dosage, and staff expressed concerns about exceeding safe acetaminophen limits due to the resident's liver condition. Facility policy required medications to be administered according to prescriber orders, but this was not followed in this instance.