Failure to Provide Timely Pain Medication Due to Refill and Documentation Lapses
Penalty
Summary
A deficiency occurred when a resident with complex regional pain syndrome, functional quadriplegia, and generalized muscle weakness did not receive a scheduled fentanyl transdermal patch at the prescribed time. The resident was cognitively intact at admission but later became moderately impaired. On the scheduled day, the fentanyl patch, which was to be applied at 9 AM, was not administered until 6:18 PM, resulting in a significant delay. The delay was due to the facility not having the fentanyl patch available at the scheduled time. Nursing staff reported that the patch had been ordered from the pharmacy five days prior, but it had not arrived by the time it was needed. The pharmacy was waiting for the physician's signature before delivering the medication, and there was no documentation showing that the refill was requested or that efforts were made to obtain the necessary signature before the scheduled administration time. Facility policy indicated that medication refills should be requested 3-5 days before depletion, but there was no evidence that this process was followed for the resident's fentanyl patch. The facility's Assistant Director of Nursing acknowledged that the scheduled dose was not applied on time and that there was no documentation of a timely refill request or physician signature prior to the missed dose.