Failure to Ensure Timely Receipt of Ordered Pain Medications
Penalty
Summary
The facility failed to ensure the timely acquisition and receipt of ordered medications for two residents with complex medical conditions and ongoing pain management needs. One resident, who was cognitively intact and had spinal stenosis and thoracic vertebrae fractures, had an active order for Morphine ER 30 mg every 12 hours for pain. This resident did not receive three consecutive doses as documented in the Medication Administration Records, with progress notes indicating the medication was pending or awaiting pharmacy delivery. The resident confirmed missing doses of prescribed pain medication due to the facility running out of the medication. Another resident, also cognitively intact and with lumbar stenosis and back pain, had an order for Norco 5-325 mg three times daily for pain. This resident missed four consecutive doses, with progress notes and staff interviews confirming the medication was not available and was awaiting pharmacy delivery. Both residents and staff acknowledged the missed doses, and the Director of Nursing Services confirmed the failures were due to medications not being received from the pharmacy in a timely manner.