Failure to Timely Process and Administer Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when staff did not process an ordered narcotic pain medication, Tramadol 50 mg, in a timely manner for a resident with moderate cognitive impairment and heel wounds. The resident was re-admitted with a care plan indicating a risk for pain related to stroke, and interventions included administering pain medication as ordered. Despite a physician order for Tramadol to be given twice daily, the medication was not delivered promptly by the pharmacy, and staff did not promptly contact the physician to ensure the prescription was processed. Documentation in the medical record and Medication Administration Record (MAR) showed that the resident missed a total of six doses of Tramadol over several days. Progress notes indicated that the medication was unavailable and that the pharmacy was waiting for a signed prescription. Staff administered acetaminophen as needed in place of the ordered Tramadol. The facility's emergency stock (e-kit) contained Tramadol, but staff were unable to access it because the pharmacy required a signed prescription before providing the access code. Interviews with staff revealed that the nurse practitioner (NP) who wrote the order did not have a DEA number, which prevented the pharmacy from filling the prescription. The process for obtaining the necessary prescription signatures was not clearly defined, and staff did not have a protocol to ensure timely processing of narcotic orders. The Director of Nursing confirmed that the resident did not receive any Tramadol until several days after the order was written, and that staff had documented administration of the medication when it was not actually available.