Failure to Ensure Timely Pain Medication Procurement and Accurate Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure timely procurement of pain medication and accurate accounting of controlled substances for a resident admitted with significant pain following an arterial bypass surgery. Upon admission, the resident reported severe pain and was unable to walk due to surgical incisions with staples in place. Despite a physician's prescription for hydrocodone being signed prior to admission and faxed on the day after admission, there was no documentation of efforts by the facility to obtain the medication from the time of admission until more than 24 hours later, resulting in a delay in pain management. Review of the resident's records showed ongoing reports of moderate to severe pain, with pain levels frequently documented as 7 or higher on a 10-point scale. The Medication Administration Record (MAR) and the Medication Monitoring Control Record for hydrocodone did not match, with several instances where withdrawals of the medication were not documented on the MAR. The facility's policy required that the dose noted on the usage form or dispensing system must match the dose recorded on the MAR and controlled drug record, but this was not followed in this case. Interviews with facility staff, including the DON and pharmacy consultant, confirmed that medications for new admissions should be received by the next pharmacy delivery and that documentation should be consistent between records. However, the facility lacked a policy and procedure for timely medication procurement, and staff acknowledged the discrepancies between the MAR and control records. These failures resulted in both a delay in pain medication administration and inaccurate accounting of controlled substances for the resident.