Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to ensure that a resident received their prescribed pain medication, oxycodone, as ordered by the physician. According to the facility's policy, medications are to be administered in a safe and timely manner, with reordering procedures in place to prevent interruptions. Documentation showed that the resident's supply of oxycodone ran out, and there was a gap of several days before the medication was available again. During this period, the resident was given tramadol instead, which they reported was ineffective for their pain. The resident stated they had to wait three to four days without their prescribed oxycodone. Staff interviews revealed that medication reordering was supposed to occur when a four to five day supply remained, but there was confusion and lack of documentation regarding when the refill was requested. The LPN involved was unsure of the exact timing of the request and noted difficulty obtaining the necessary prescription due to the physician being out of the office for a holiday. The DON confirmed that the request was not made until the medication had already run out and acknowledged that there was a breakdown in communication between the facility and the physician, resulting in the resident not having access to their prescribed narcotic.