Missed Pain Medication Dose Due to Unavailable Medication
Penalty
Summary
A resident with a history of systemic lupus erythematosus, chronic pain syndrome, and unspecified dementia was admitted to the facility and had an active order for hydrocodone-acetaminophen to be administered every 8 hours for chronic pain. On the morning in question, the resident did not receive her scheduled 6 AM dose of hydrocodone-acetaminophen. Review of the Medication Administration Record confirmed the missed dose, and the nurse's progress note indicated the medication was not available and was being awaited from the pharmacy. During interviews, the resident reported that hydrocodone-acetaminophen was the only medication that effectively managed her pain and that it was not always available when requested, describing this as an ongoing issue. The nurse and DON both confirmed that the process for unavailable medications should involve contacting the pharmacy to access the emergency kit, which was not done in this instance. Facility policy indicated that effective pain management requires around-the-clock medication, but this was not achieved due to the missed dose.