Failure to Provide Timely Pain Medication Due to Pharmacy and Reordering Issues
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of a resident with complex pain management requirements. The resident, admitted with systemic sclerosis with polyneuropathy, bilateral below-knee amputations, phantom limb pain, muscle spasms, type 2 diabetes with neuropathy, and chronic pain, was prescribed multiple pain medications including Gabapentin, Methadone, hydromorphone (Dilaudid), and Acetaminophen. There were repeated instances where the facility ran out of the resident's pain medications, particularly Methadone and Dilaudid. Staff interviews confirmed that medication shortages had occurred, with the Assistant Director of Nursing (ADON) acknowledging ongoing issues with pharmacy supply and timely reordering, despite previous attempts to resolve the problem. On the day of the survey, the resident reported not receiving Methadone since the previous night due to the facility being out of stock, a situation corroborated by both nursing staff and the ADON. The ADON indicated that the pharmacy had flagged the medication order, but there was no notification received that morning, and the medication had not arrived as expected. The issue was attributed to problems with pharmacy communication, medication dosage flagging, and delays in reordering, resulting in the resident not receiving prescribed pain management as ordered.