Failure to Ensure Timely Administration of Pain Medications Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of routine and emergency drugs for three residents. In each case, residents did not receive their prescribed pain medications as ordered by their physicians, resulting in missed doses. For one resident with fibromyalgia and chronic pain syndrome, three doses of Hydrocodone-Acetaminophen were missed in a single day due to the medication not being available. The nurse was unable to obtain the medication from the emergency kit because the pharmacy required an updated order, and the resident was given Tylenol as an alternative until the medication arrived later that day. Another resident with a history of fractures did not receive two scheduled doses of Oxycodone HCL because the medication was not available at the facility. The pharmacy was contacted and reported that the medication would be delivered in the evening, and the resident received an alternative pain medication in the interim. The resident was away from the facility for several other scheduled doses that day, and the first dose of the new supply was administered in the evening. A third resident with multiple diagnoses, including chronic pain and neuropathic pain, missed two doses of Hydrocodone-Acetaminophen because the facility ran out of the medication. The emergency kit was used to provide some doses, but the regular supply was not available until later. Interviews with staff revealed issues with timely reordering of medications, communication lapses with the pharmacy, and confusion regarding the process for obtaining emergency medications. The facility did not provide a policy regarding the reordering of narcotic medications when requested.