Failure to Provide Timely Pain Medication Administration
Penalty
Summary
The facility failed to ensure timely administration and refilling of pain medications for a resident with multiple diagnoses, including morbid obesity, diabetes, peripheral vascular disease, and depression. The resident experienced uncontrolled pain and elevated blood pressure after not receiving scheduled doses of morphine due to a pharmacy shipment delay. Documentation showed that the last dose of morphine was administered in the morning, and subsequent scheduled doses were not given because the medication was not available. Additionally, there was a significant delay in administering as-needed oxycodone, with nearly twelve hours between doses, despite the resident's ongoing pain. Progress notes and medication administration records confirmed that both morphine and oxycodone were available in the facility's back-up medication supply at the time, but were not pulled or administered as per physician orders. Interviews with the Director of Nursing revealed that nurses are expected to check and pull medications from the back-up supply when a resident runs out, especially for controlled substances, but this was not done. The facility's provided medication administration policy did not address procedures for accessing the back-up supply, contributing to the failure to provide appropriate pain management, which resulted in the resident being transferred to the emergency room for pain control.