Failure to Safeguard Controlled Substances Results in Unmanaged Pain
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for residents requiring such services by not safeguarding and accounting for controlled substances, which led to the diversion of narcotic medications by a staff member. This resulted in ordered pain medications not being available for administration, causing unmanaged pain and discomfort for three residents. A comparison of medication counts and controlled substance record sheets revealed discrepancies, and an investigation found that scheduled narcotic pain medications were not administered as ordered. One resident with chronic pain syndrome, osteomyelitis, and peripheral vascular disease reported almost constant pain with high intensity and did not receive scheduled doses of oxycodone. The resident stated he was in severe pain for two days due to missed doses. Another resident with liver cancer and chronic pain, who was also receiving hospice services, missed a dose of morphine and reported severe pain, stating he cried because the pain was so bad. A third resident with pain, major depressive disorder, and personality disorder missed a dose of oxycodone-acetaminophen and reported increased pain, with staff unable to provide the medication due to its unavailability. Documentation in the medical records was incomplete, with no pain assessments or evidence that staff assessed or addressed the residents' pain or notified providers about missed medications. Interviews with staff confirmed that residents' complaints of pain were not properly documented or communicated to providers, and the controlled substance counts were inaccurate. The facility's failure to follow its own policies for controlled substance management and pain assessment led to residents experiencing unmanaged pain due to missed doses of prescribed narcotic medications.