Failure to Notify Physician and Representative of Unavailable Pain Medication
Penalty
Summary
The facility failed to timely notify the attending physician, hospice provider, and the resident's representative regarding the unavailability of a prescribed pain medication for a resident with severe dementia, late-onset Alzheimer's disease, and polyosteoarthritis, who was also receiving hospice services. The resident did not receive the physician-ordered Norco (hydrocodone/acetaminophen) for pain management from the morning dose on May 21 through the evening dose on May 26, as documented in the Medication Administration Record and narcotic log. Nursing notes during this period repeatedly indicated the medication was not available, was on order, or had been reordered, but there was no documentation of consistent or ongoing notification to the physician, hospice, or the resident's responsible party about the continued lack of medication. Observation and record review confirmed that the resident was nonverbal and unable to communicate needs, further emphasizing the importance of timely notification and intervention. Facility policy required immediate action and notification to the physician and family when medications were unavailable, but documentation showed only a single instance of attempted communication with hospice and no evidence that the resident's representative was informed. The lack of documentation and follow-through on required notifications contributed to the deficiency cited during the complaint investigation.