Failure to Ensure Timely Ordering and Availability of Pain Medication
Penalty
Summary
The facility failed to ensure that medications were ordered in a timely manner and available for administration, resulting in a resident not receiving prescribed pain medication as ordered. The resident, who had a history of traumatic brain injury, quadriplegia, neuropathy, muscle spasms, and chronic pain, was dependent on staff for most activities of daily living and received opioid medication for pain management. The care plan included both pharmacological and non-pharmacological interventions for pain, and the resident was scheduled to receive Percocet multiple times daily. On one occasion, the resident was out of Percocet for approximately 30 hours, missing five scheduled doses. Documentation showed that the facility had recently switched to a new pharmacy, which led to issues with the timely delivery of narcotic medications. Staff were unable to access emergency stock, and there was a delay in the pharmacy receiving and processing the prescription from the pain management clinic. During this period, the resident expressed concern about withdrawal symptoms and was offered transport to the emergency room, which was declined. Interviews with staff and review of records confirmed that the medication was not available due to the pharmacy transition and delays in prescription processing. The resident reported that this was not the first time such an incident had occurred and was told that future orders would be placed earlier to prevent recurrence. The deficiency was confirmed by the DON, who verified the missed doses and the duration the resident went without the ordered pain medication.