Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to provide pain medication as ordered for one resident, resulting in a missed dose of Oxycodone 10 mg for non-acute pain. The resident, who had a history of spinal stenosis, neuralgia, neuritis, monoarthritis, and unspecified pain, reported issues with receiving pain medication over the past month. Record review confirmed that the medication count for Oxycodone reached zero on 4/25/2025, and a dose was missed on 4/26/2025. The prescription for the medication was faxed to the pharmacy on the morning of 4/26/2025, but the medication was not delivered until after 7:30 p.m. that day. Interviews with nursing staff and pharmacy representatives revealed that the process for obtaining narcotics from the automated medication dispensing machine was not consistently followed, and there was confusion regarding when and how to access emergency supplies. Staff indicated that nurses are expected to reorder narcotics when the count reaches ten pills, and that a warning is present on the medication card to prompt reordering. However, the medication was not reordered in time, and the resident went without the prescribed pain medication. The facility's policy requires timely communication of orders to the pharmacy, but this process was not effectively implemented in this instance.