Failure to Provide Timely Pain Medication Due to Pharmacy and Communication Delays
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided to meet the needs of a resident with a history of chronic pain and a shoulder fracture, who was dependent on Morphine for pain management. The resident had a care plan and physician orders for Morphine 30 mg extended release to be administered twice daily. However, a breakdown in communication and medication management led to the resident missing multiple doses of their prescribed Morphine. Documentation showed that the medication was not available due to delays in obtaining a new prescription and confusion between immediate release and extended release formulations, resulting in the pharmacy not dispensing the medication on time. Nursing staff documented that the Morphine was on order and not available, and communicated with the pharmacy and provider regarding the need for a new prescription. Despite these communications, there was a lapse of at least two doses before the medication was received. The resident reported experiencing unrelieved pain and withdrawal symptoms during this period, and staff notes confirmed the resident endorsed withdrawal after missing the doses. The facility's policy required nurses to reorder medications when a seven-day supply remained, but staff interviews revealed inconsistent understanding and application of this policy, with some staff unaware of the missed doses until after the fact. Interviews with the resident, their spouse, and various staff members indicated that the resident's complaints of pain and withdrawal were not taken seriously at the time, and there was a lack of timely communication and oversight by nursing management. The provider confirmed that the interruption in Morphine administration was not planned or recommended, and there was no documentation of provider-patient communication regarding the missed medication. The failure to provide the ordered medication as required by the care plan and physician orders resulted in the resident experiencing unmanaged pain and withdrawal symptoms.