Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive scheduled pain medication, specifically Oxycontin extended release, as ordered for several days. The resident reported experiencing severe pain and stated that he had not received his pain medication for three days, with one instance where it took over six hours to receive the medication, which he subsequently vomited. Interviews with nursing staff confirmed that the resident missed multiple doses of Oxycontin due to a lapse in obtaining a new prescription when the previous supply ran out. The Medication Administration Record (MAR) corroborated that several scheduled doses were not administered as ordered. The resident had a complex medical history, including metabolic encephalopathy, sepsis, diabetes, chronic heart failure, cellulitis, acute kidney failure, cardiomyopathy, chronic venous hypertension with ulcers, depression, varicose veins, and lymphedema. The resident was cognitively intact and had a care plan in place that included scheduled administration of pain medication to manage chronic pain and minimize interruptions to daily activities. Despite these orders and care plan interventions, the facility failed to ensure the resident received the prescribed Oxycontin for pain management on multiple occasions. Record reviews and staff interviews revealed that the pharmacy dispensed an incomplete supply of Oxycontin, and when the medication ran out, nursing staff did not promptly contact the provider for a new prescription. There was no documentation in the progress notes indicating that the physician was notified about the missed doses or that a refill was requested in a timely manner. The facility's medication administration policy required medications to be administered as ordered and for medication errors to be documented and reported, but these procedures were not followed in this instance.