Failure to Timely Obtain and Administer Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were obtained and available for administration to three residents as ordered by their physicians. For one resident with a history of GERD and recent bilateral leg fractures, hydrocodone-acetaminophen was not available for several scheduled doses, resulting in missed pain medication. The resident reported that the facility often ran out of her pain medication, and the DON confirmed that staff were not reordering medications in a timely manner when supplies were low. Another resident with chronic pain due to migraine and sciatica missed multiple scheduled doses of oxycodone, with documentation showing several instances where the medication was not administered as ordered. The resident reported severe pain during these periods without medication. A third resident, with diagnoses including anxiety and schizoaffective disorder, did not receive scheduled doses of clonazepam on multiple occasions due to delays in reordering and waiting for a new prescription. The DON acknowledged that the medication had not been reordered timely, and the facility's policy required a valid prescription before narcotics could be ordered from the pharmacy.