Failure to Ensure Accurate Pain Management and Medication Documentation
Penalty
Summary
Facility staff failed to ensure an effective and accurate pain management program for a resident requiring scheduled opioid pain management. Staff did not maintain an adequate supply of fentanyl transdermal patches, resulting in multiple instances where the resident did not receive the prescribed medication as ordered. Documentation showed that staff recorded administration of fentanyl patches even when no patches were available or applied, and failed to accurately document the location and status of the patches on the resident. There were also discrepancies between the Medication Administration Record (MAR), Controlled Drug Receipt Records, and progress notes, with staff documenting the presence of patches that were not actually in place. The resident involved had diagnoses including cerebral infarction, osteoarthritis, and unspecified pain, and was on a scheduled pain medication regimen. Despite clear physician orders and care plan instructions for pain management, staff did not reorder fentanyl patches in a timely manner, leading to gaps in administration. When patches were unavailable, staff did not consistently utilize the facility's emergency kit or notify the physician about missed doses or the presence of an outdated patch. Staff also failed to follow facility policy regarding the destruction of narcotic patches and did not document follow-up actions related to drug interaction alerts. Interviews with nursing staff and facility leadership confirmed that staff were aware of the lack of available fentanyl patches and the presence of an expired patch on the resident, but did not take appropriate steps to resolve the issue or ensure accurate documentation. The Director of Nursing and other staff acknowledged that policies for medication administration, documentation, and reordering were not followed. These failures resulted in the resident not receiving prescribed pain management and inaccurate medical records.