Failure to Maintain Controlled Medication Supply in Emergency Kit
Penalty
Summary
A deficiency occurred when the facility failed to maintain an effective system for acquiring and maintaining the supply of controlled medications in the emergency kit, resulting in a resident not having access to prescribed as-needed pain medication upon admission. The resident, who had recently undergone joint replacement surgery and had a history of hypertension and type 2 diabetes, was admitted late in the evening and was informed that his medications would not be available for at least 12 hours. Despite staff responding to his requests, the specific pain medication that was effective for him was not available, leading the resident to call 911 and request transport to the hospital for pain management. The physician's orders for the resident included multiple controlled pain medications, such as oxycodone, tramadol, acetaminophen, and hydromorphone. Upon review, it was found that while some medications were administered from the emergency kit, oxycodone was not available as it had run out, and hydromorphone was not stocked in the kit. Staff interviews revealed that the process for reordering controlled medications for the emergency kit was not consistently followed, with confusion over the correct procedure for submitting DEA 222 forms to the pharmacy. The DON admitted to changing dates on the form and faxing it instead of sending the original, contrary to pharmacy policy, and there was a lack of documentation regarding inventory checks and declining count sheets for the controlled medications. Further interviews with pharmacy staff confirmed that the pharmacy only dispensed controlled medications upon receipt of the original DEA 222 form and did not have records of emergency requests or faxes from the facility during the relevant period. The pharmacy manager and president both stated that the process required the original form to be placed in the pharmacy tote for courier pickup, and that medications could be ordered for replacement seven days a week. The lack of adherence to these procedures resulted in the emergency kit not being restocked in a timely manner, directly impacting the resident's access to necessary pain medication.