Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A resident with multiple complex diagnoses, including polyneuropathy, spinal fusions, and several fractures, was admitted to the facility and had a physician's order for Lyrica (Pregabalin) 100 mg every eight hours for pain management. Despite this order, the resident did not receive the prescribed pain medication for approximately 36 hours, missing four doses, because the facility was waiting for the pharmacy to deliver the medication. Nursing progress notes documented the delay, but there was no evidence that the physician was notified about the missed doses or that an alternative pain medication was offered during this period. The resident reported severe pain, rating it as nine or ten out of ten, and stated that the pain prevented him from sleeping. Nursing staff confirmed the medication was not available and had not been administered as scheduled, despite documentation on the medication administration record indicating otherwise. The unit manager stated that the expectation was for nurses to reorder medications before running out to prevent interruptions, which did not occur in this case, resulting in a failure to provide timely and appropriate pain management.