Failure to Ensure Timely Refill of Pain Medication
Penalty
Summary
A resident with a diagnosis of chronic pain was admitted to the facility and had an order for oxycodone to be administered every eight hours as needed for pain. The resident's medication administration record (MAR) and order summary reports indicated that oxycodone was to be refilled by a specific physician. On several occasions, the resident did not receive the prescribed oxycodone due to issues with obtaining a timely refill. Progress notes documented that the pharmacy placed the medication on hold pending clarification of the prescribing physician, and staff were unable to use the emergency supply. As a result, the resident missed multiple doses of oxycodone. The resident expressed difficulty participating in daily activities and getting out of bed without the pain medication and refused showers until the medication was reordered. Staff interviews confirmed that attempts were made to refill the prescription at least a week in advance, but delays occurred due to communication issues with the clinic and pharmacy. The Director of Nursing Services acknowledged the need for a system to ensure timely medication refills. The failure to provide the prescribed pain medication as ordered resulted in the resident experiencing periods without adequate pain control.