Failure to Ensure Timely Refill and Administration of Scheduled Opioid Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain effective systems for acquiring and administering a scheduled opioid pain medication, tramadol, resulting in a resident missing three consecutive days of their prescribed pain management. The resident, who had osteoporosis and was receiving tramadol 50 mg once daily for generalized pain, did not receive the medication as ordered due to lapses in the medication refill process and lack of timely action by nursing staff. The Medication Administration Record showed that after the last dose was given, subsequent scheduled doses were not administered, and appropriate documentation was lacking for at least one of the missed doses. The breakdown began when the nurse who administered the last available tablet did not request a new prescription, and subsequent nurses also failed to initiate the refill process in a timely manner. One nurse attempted to start the refill but was delayed by the need for a nurse practitioner's signature and did not escalate the issue to the Director of Nursing. Additionally, attempts to access tramadol from the facility's Pyxis automated dispensing system were unsuccessful due to login issues, and the nurse did not notify supervisory staff about this barrier. Communication between shifts occurred, but the medication was still not obtained from the Pyxis or a local back-up pharmacy, despite these resources being available. Interviews with staff and the nurse practitioner revealed that the expectation was for nurses to begin the refill process 5-7 days before the medication ran out, especially for controlled substances. The failure to follow this protocol, combined with ineffective use of available pharmaceutical resources and lack of urgency among staff, led to the resident missing three days of scheduled pain medication.