Failure to Maintain Adequate Pain Medication Supply Resulting in Resident Harm
Penalty
Summary
The facility failed to maintain an adequate stock of controlled substances necessary for effective pain management, resulting in actual harm to two residents. For one resident with a history of rheumatoid arthritis, osteoarthritis, and temporomandibular joint disorder, scheduled Methadone was not administered for several consecutive days due to the medication being out of stock. Documentation showed that the resident experienced severe pain, rating it as a 10 out of 10, and expressed distress over not receiving the prescribed pain medication. Nursing notes confirmed the medication was unavailable, and pharmacy communication revealed a delay in obtaining a new prescription, during which the resident's pain was not adequately controlled despite the use of as-needed Oxycodone, which was sometimes ineffective. Another resident, who had an amputation and chronic pain syndrome, also experienced a lapse in receiving scheduled Oxycodone for pain management. The resident missed eight scheduled doses over approximately 36 hours because the medication was not reordered in a timely manner. Staff documentation and interviews confirmed that the resident reported severe pain, including phantom limb pain, and was observed in significant distress, unable to get out of bed. Attempts to use backup stock were unsuccessful due to prescription mismatches, and the delay in notifying the physician and pharmacy further prolonged the period without adequate pain control. Interviews with staff and the medical director revealed that medication reorder requests were often delayed until supplies were depleted, preventing timely intervention by physicians and pharmacies. Facility policy required staff to administer medications as ordered and to notify the physician if pain management was ineffective, but these protocols were not followed, resulting in residents experiencing unmanaged pain. The deficiency was substantiated by direct observations, record reviews, and staff and resident interviews.