Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed pain medication to two residents, resulting in missed doses and unmanaged pain. One resident, who was cognitively intact and suffered from phantom limb pain and a wound infection, missed six doses of oxycodone over a three-day period. The resident reported significant pain during this time, stating that the medication had run out and expressing uncertainty about whether the issue was due to a failure to reorder or a delay in pharmacy delivery. Documentation confirmed the missed doses, and staff interviews indicated that the prescription had expired and there was a possible change in providers. Another cognitively intact resident also missed three doses of prescribed oxycodone. Nursing notes revealed that the pharmacy had only partially filled the order, and a new prescription from the physician was required. Staff interviews acknowledged that running out of pain medication sometimes occurred, especially during pharmacy transitions or when new prescriptions were needed. The facility's policy required staff to check for misplaced medications, contact the pharmacy, use contingency supplies if available, and notify the physician if orders could not be followed, but these steps were not effectively implemented, resulting in the residents not receiving their prescribed pain management.