Failure to Provide Ordered Pain Medication Due to Medication Unavailability and Poor Communication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple significant medical conditions, including paraplegia and several displaced fractures. The resident had a physician's order for Lidocaine Pain Relief External Patch 4% to be applied daily for pain management, but the medication was not administered on 21 documented occasions over a period of nearly a month. Medication Administration Records (MARs) indicated missed doses, often marked with a code that should have been explained in the resident's progress notes, but no such documentation was found. There were also instances of blank spaces in the MAR, indicating the medication was not given, with no explanation provided. Interviews with facility staff revealed that the missed administrations were due to the facility not having the medication available. Staff, including medication aides and nurses, acknowledged that it was their responsibility to ensure medications were in the building and to notify the appropriate personnel, such as the DON and NP, when medications were unavailable. However, there was a lack of consistent communication and documentation regarding the unavailability of the medication and the steps taken to address it. The nurse practitioner was not informed about the missed doses and stated she could have considered alternative pain management if she had been notified. The resident reported not receiving the lidocaine patch about 20% of the time and expressed feelings of neglect due to not receiving ordered medications. Staff interviews confirmed that the resident sometimes received only one patch instead of two, and that the facility occasionally attempted to purchase the patches over the counter when the pharmacy did not supply them. The facility's own policies required a medication management program to ensure residents' needs were met, but these procedures were not followed, resulting in the resident not receiving prescribed pain management as ordered.