Failure to Timely Reorder and Administer Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's supply of Morphine Sulfate, a medication prescribed for pain management, was restocked and available when needed. The resident, who had diagnoses including Parkinson's disease, dementia, and type 2 diabetes mellitus, was dependent on staff for daily care and had moderate cognitive impairment. The medication order required Morphine Sulfate 15 mg to be administered every 12 hours. According to the Medication Administration Record, the resident did not receive three scheduled doses because the medication supply ran out. The Director of Nursing confirmed that the supply was depleted due to the ordering physician not signing for the refill in time. The contracted pharmacist stated that the refill request was not processed until after the supply had already run out, and that the pharmacy did not begin the refill process until the day after the medication was depleted. Facility policy required that medications, especially Schedule II controlled substances like Morphine, be reordered when a three to five-day supply remained, and specifically that the pharmacy be notified when a five-day supply remained. The failure to follow these procedures resulted in the resident missing multiple doses of prescribed pain medication.