Failure to Ensure Timely Reordering and Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure the timely reordering and availability of a prescribed controlled pain medication, oxycodone, for a resident with chronic gout and a history of multiple gout attacks. The resident was admitted with decision-making capacity and had a physician's order for oxycodone 5 mg, two tablets by mouth every four hours for pain management. A refill request for 48 tablets was submitted and delivered, but based on the prescribed dosing schedule, the supply would have been depleted by June 25. There was no documentation that a refill was requested before the supply ran out, resulting in a missed scheduled dose on June 26, as documented in the Medication Administration Record and nursing notes. Interviews with nursing staff and review of facility policies revealed that nurses were expected to request medication refills when three to six doses remained, and best practice was to fax refill requests three to five days before depletion. However, the licensed nurse did not request a refill in time, and when the medication ran out, there was no oxycodone available in the emergency kit. This led to the resident missing a scheduled dose of pain medication, as confirmed by both the resident and staff interviews.