Failure to Ensure Timely Ordering and Administration of Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely ordering and administration of pain medications for two residents. For one resident, who had a history of congenital malformation of the nervous system, somatization disorder, and spinal fusion, the facility did not order her prescribed Percocet (oxycodone with acetaminophen) in a timely manner, resulting in her missing 18 doses over several days. Documentation showed that the resident experienced significant discomfort, including headaches, sore throat, burning sensations, and reported withdrawal symptoms. The resident refused alternative pain medications offered, such as tramadol and ibuprofen, citing adverse effects, and only agreed to take Tylenol at one point. Progress notes indicated ongoing somatic complaints and repeated requests for her prescribed medication, with delays attributed to issues in obtaining the necessary triplicate prescription forms for controlled substances. A second resident, with diagnoses including hip fracture and above-the-knee amputation, also experienced a lapse in receiving his prescribed oxycodone for pain management. The medication was not ordered in advance, resulting in the resident being without his pain medication for less than 24 hours. The resident reported a moderate pain level and was unaware that the facility had run out of his medication until informed by staff. Interviews with nursing staff revealed a lack of a formal policy for timely medication ordering, and staff typically ordered medications only a few days before they were due to run out. Administrative interviews confirmed the absence of a policy or systematic process for monitoring medication supplies and ensuring timely reordering. Nurse management was identified as responsible for overseeing medication ordering, but there was no clear method in place for monitoring this process. The administrator acknowledged that running out of pain medication could result in residents experiencing severe pain, and was only aware of one resident's medication lapse at the time of the survey.