Failure to Timely Administer Prescribed Pain Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed pain medication for one resident who was admitted with diagnoses including muscle wasting and atrophy, COPD, and chronic pain syndrome. Despite a physician's order for Xtampza ER, an extended-release oxycodone for pain management, the medication was not administered at the scheduled times from the evening of admission through several subsequent scheduled doses. The resident, who was cognitively intact, reported not receiving the medication and experiencing significant pain, rating it as 8.5 out of 10. Facility policy required pharmacy services to be available 24/7 and for nursing staff to ensure residents have a sufficient supply of prescribed medications, including timely communication with the pharmacy if medications are unavailable. Documentation and interviews confirmed that the resident did not receive the ordered pain medication due to a delay in delivery from the pharmacy, resulting in unmet pain management needs.