Failure to Provide Timely Pain Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's pain medication, specifically a Fentanyl Duragesic patch, was available and administered in a timely manner. The resident, who had diagnoses including depression and pain and was assessed as cognitively intact, was care planned to receive pain medication as ordered. The medication administration record showed that the pain patch was due but not administered on the scheduled date because it was unavailable. The resident reported not having her pain patch for two days, and documentation indicated that the pharmacy was not notified until one day after the missed dose. The clinical record lacked evidence of timely notification to the physician or pharmacy regarding the unavailability of the medication. Facility policy required immediate action and notification to the pharmacy upon discovery of a medication shortage, but this procedure was not followed. Interviews with facility leadership confirmed that it was the facility's responsibility to ensure medication availability for residents.