Failure to Provide Scheduled Pain Medication and Investigate Medication Unavailability
Penalty
Summary
The facility failed to ensure that a resident with severe dementia, late-onset Alzheimer's disease, and polyosteoarthritis received physician-ordered pain medication (Norco 5-325 mg) as scheduled for five consecutive days. The resident, who was also receiving hospice services, did not receive the medication from the morning dose on 5-21 through the evening dose on 5-26, as documented in the Medication Administration Record (MAR) and narcotic record. 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 the medication being administered until after the gap. The facility's records showed that 56 tablets were received from the pharmacy on 5-26, but there was no time of receipt noted. During this period, there was no evidence that the resident's responsible party was notified about the missed doses, nor was there consistent documentation of communication with the medical provider or hospice regarding the unavailability of the medication. The only documented communication to the provider was on the first day the medication was unavailable. The facility's policies require immediate action when medications are unavailable, including notifying the physician, obtaining alternative orders, and monitoring the resident, but these steps were not documented as being followed. Interviews with facility leadership, including the Executive Director, DON, and Assistant DON, revealed they were unaware of any medication errors or issues with scheduled pain medication for residents during the relevant period. The Corporate Nurse later confirmed that staff had reached out to hospice for a new prescription, as hospice was responsible for the order, but was unable to locate documentation of this communication for the period in question. The lack of timely administration of pain medication and failure to follow policy for unavailable medications and medication errors led to the deficiency.