Failure to Timely Reorder Pain Medication Resulting in Resident Discomfort
Penalty
Summary
The facility failed to ensure that a resident's pain medication, Hydrocodone-Acetaminophen, was reordered from the pharmacy at least seven days in advance, as required by the facility's policy and procedure for medication ordering and receiving. The resident, who had chronic pain, a stage 4 pressure ulcer, and acute osteomyelitis, was admitted with intact cognition and required substantial assistance with activities of daily living. The physician's order specified the use of Hydrocodone-Acetaminophen for moderate to severe pain. On the day in question, the authorization form for the pain medication refill was faxed to the resident's physician, but the physician was unavailable to sign until several days later. The refill authorization was eventually received and sent to the pharmacy, but the medication was not delivered or available for administration on the day the resident requested it. The Medication Administration Record confirmed that the resident did not receive the pain medication on that day. Interviews with the resident and nursing staff confirmed that the resident experienced pain and was informed by staff that the medication was unavailable and needed to be reordered. Staff acknowledged the importance of timely medication ordering and the negative impact of pain on the resident's well-being. The facility's policy required controlled substances to be reordered at least seven days in advance, but this was not followed, resulting in the resident being without necessary pain medication.