Failure to Ensure Timely Availability of Prescribed Pain Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure the availability of prescribed pain medication for a resident admitted for rehabilitation following multiple fractures sustained in a motor vehicle accident. The resident had orders for both extended-release and immediate-release morphine for pain management. Over a weekend, the resident's supply of morphine ran out, and no refills were available. The medication was not reordered in advance, and there was no in-house provider available to write a new prescription during the weekend. When the resident requested pain medication, the LPN discovered that the medication was depleted and that the back-up medication room did not have additional morphine. Attempts to substitute with oxycodone were unsuccessful due to insufficient supply. The telehealth physician recommended sending the resident to the emergency department (ED) for pain management, as the facility could not provide the necessary medication. The resident experienced significant pain and discomfort during this period, as well as frustration and agitation, as documented in behavior notes. Interviews with facility staff, including the LPN, ADON, and DON, confirmed that the medication should have been reordered before running out and that the pharmacy should have been contacted for refills or a new prescription. Facility policy required nurses to request refills 2-3 days before depletion and to use emergency pharmacy services if needed. The failure to follow these procedures resulted in the resident being sent to the ED for pain control due to the unavailability of prescribed medication.