Failure to Ensure Availability of Ordered Pain Medication
Penalty
Summary
Facility staff failed to ensure that a medical provider-ordered narcotic pain medication, Oxycontin, was available for administration to a resident on six separate occasions. The resident, who was cognitively intact and had multiple diagnoses including hemiplegia, muscle weakness, chronic kidney disease, and seizure disorder, reported to the surveyor that staff had previously allowed their scheduled pain medication to run out. Review of the clinical record confirmed that Oxycontin was not administered at the scheduled times due to the medication being unavailable, as documented in nursing progress notes and verified by the Director of Nursing and Regional Nurse Consultant. The medication was not present in the facility’s onsite medication supply system (Pyxis) and was not sent by the pharmacy as required. The facility’s policy on administering medications states that medications are to be administered in accordance with prescriber orders. Despite this, the resident’s Oxycontin was not available for administration on multiple occasions, and facility leadership could not provide an explanation for why the medication was not sent by the pharmacy or available onsite. No additional information regarding the unavailability of the medication was provided to the survey team prior to the exit conference.