Failure to Provide Timely Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that a prescribed pain medication, Fentanyl 12mcg/hr transdermal patch, was available and administered as ordered for a resident with multiple diagnoses, including end stage renal disease, hemiplegia, and chronic pain. The resident's care plan required pain management, and physician orders specified the application of the Fentanyl patch every 72 hours. However, the medication administration record showed that the patch was not applied for a period of seven days, and progress notes indicated the medication was not available during this time. Interviews with nursing staff revealed confusion regarding the ordering and availability of the Fentanyl patch. One LPN stated the patch was not in the facility for several days, despite the pharmacy delivering medications multiple times daily and the medication being listed in the facility's emergency narcotic supply. The Director of Nursing confirmed that a current prescription was needed for the pharmacy to supply the narcotic and that the process involved contacting the nurse practitioner if a prescription was missing. Documentation showed the prescription was received on one date, but the medication was not delivered until several days later, and the patch was not applied until even later, resulting in a gap in pain management for the resident.