Failure to Administer Scheduled Pain Medication Due to Unavailable Stock
Penalty
Summary
A significant medication error occurred when nursing staff failed to administer a scheduled dose of Methadone to a resident with a history of multiple fractures and chronic pain. The resident was prescribed Methadone 35 mg by mouth twice daily for pain management, but the morning dose on 04/16/2025 was not given because the medication was not available at the facility. The Medication Administration Record indicated the dose was missed, and pharmacy records showed the medication was delivered later that day. The resident, who had moderately impaired cognition and a history of severe injuries from an automobile accident, reported missing the morning dose and experiencing a lack of energy that day. The resident expressed confusion about why the medication was not kept in stock, especially since it was a long-standing prescription. Interviews with nursing staff confirmed the medication was unavailable during the morning pass, and the nurse did not contact the physician but did notify the pharmacy and the oncoming nurse. Further interviews with the physician and Physician Assistant revealed they were not initially aware of the missed dose, and both emphasized the importance of having medications available and reordering before supplies run out. The Director of Nursing and the Administrator acknowledged awareness of the missed dose and stated that medications should be available as ordered, with staff responsible for timely reordering to prevent such occurrences.