Failure to Administer Pain Medication as Ordered Due to Medication Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident with complex medical needs, including a persistent vegetative state, chronic pain, and a stage 4 sacral pressure ulcer. The resident was prescribed a fentanyl transdermal patch to be applied every 72 hours for pain management, as well as scheduled oxycodone via PEG tube. Multiple instances were documented where the fentanyl patch was not applied as ordered due to the medication not being available at the facility. These missed doses were recorded in the Medication Administration Record (MAR) and progress notes across several months, with nurses documenting the unavailability and, in some cases, the steps taken to reorder the medication. Interviews with nursing staff revealed inconsistent understanding and execution of the medication reordering process, particularly for controlled substances. Some nurses reported reordering medications by clicking a button in the electronic MAR, while others described the need for a printed prescription to be signed by a provider and faxed to the pharmacy. Agency nurses, in particular, expressed unfamiliarity with the facility's specific procedures for reordering controlled medications. There were also instances where nurses did not notify the provider when the medication was unavailable, or failed to document such notifications. The facility's Director of Nursing and Administrator both stated expectations that medications should be available and reordered when supplies are low, and that providers should be notified if medications are unavailable. However, the transition to having unit managers oversee narcotic reordering had only recently begun, and gaps in the process were evident. The resident involved was non-verbal and unable to communicate pain, making adherence to the prescribed pain management regimen especially critical. Despite the presence of scheduled oxycodone, the failure to consistently administer the fentanyl patch as ordered constituted a deficiency in meeting professional standards of quality for medication administration.