Failure to Timely Reorder and Administer Pain Medication
Penalty
Summary
The facility failed to ensure timely reordering and administration of pain medication for a resident with a history of bilateral breast cancer, bilateral leg neuropathy, and hypertension. The resident was dependent on nursing staff for most activities of daily living and required Norco for severe pain related to her cancer. According to interviews and record reviews, the resident reported having to wait two days for her pain medication and was told by nursing staff that she needed to wait for the doctor's approval before receiving it. She ultimately contacted her power of attorney to obtain pain medication from the emergency kit. Documentation revealed that the process for reordering Norco was not followed as required. The facility's protocol was to reorder pain medication when the supply was down to three days, but this was not done. The DON confirmed that the medication ran out and the doctor did not receive the faxed authorization request, resulting in a delay. The resident's medication was not filled on time, and there was a gap in both pain medication administration and pain assessments, as shown in the Medication Administration Record and pain assessment documentation. Facility records indicated that Norco was administered from the emergency medication kit only after the regular supply had run out. The Controlled Drug Record and Order Audit Report confirmed lapses in documentation and delays in reordering. The facility's policies required ongoing communication and timely implementation of medication regimens, but these were not adhered to, resulting in the resident experiencing a delay in pain management.