Missed Scheduled Pain Medication Dose Due to Medication Unavailability
Penalty
Summary
A cognitively intact resident did not receive a scheduled dose of tramadol, a pain medication, due to the facility running out of the medication. The resident was scheduled to receive tramadol four times daily and as needed, but the Medication Administration Record (MAR) showed that the 12:00 PM dose on 6/11/24 was not administered. Progress notes indicated that the medication was unavailable at the time and would be delivered later that day, but there was no documentation that the medication was retrieved from the medication tower, which was available for such situations. The Controlled Substance Proof of Use sheets confirmed that after the previous evening dose, there was no tramadol remaining on hand until a new supply arrived later the next day. The Director of Nursing confirmed that medications should be reordered before supplies run out and that the medication tower could be used to obtain medications in the interim. Facility policy also stated that staff may obtain medications from the medication tower while waiting for pharmacy delivery, but this was not done in this instance.