Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The facility failed to provide timely access to prescribed medications for a resident admitted from an acute care hospital with multiple fractures and pain management needs. Upon admission, the resident had orders for several controlled substances, including hydromorphone for pain, alprazolam and lorazepam for anxiety, and pregabalin for nerve pain. Despite these orders, the medications were not administered on the day of admission, as documented in the Medication Administration Record. The resident and family requested pain medication within two hours of arrival, but were informed that the orders needed to be cleared by the physician due to their controlled status. After six hours without receiving the prescribed medications, the resident's spouse signed the patient out against medical advice to seek medication at a hospital. Nursing notes indicated that the resident was assessed and offered alternative pain medications, which were refused, but did not document the resident's pain level. Interviews with staff revealed that the process for obtaining controlled substances required physician review and pharmacy authorization, even though some of the medications were available in the facility's Omnicell system. The facility's own investigation confirmed that the medications were not available as required and that orders should have been processed within four hours of admission. The deficiency was identified as an isolated incident involving a failure to ensure timely pharmaceutical services to meet the resident's needs.