Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to follow professional standards of practice by not ensuring timely follow-up on a physician-ordered pain medication for a resident with chronic pain, osteoarthritis, obesity, and depression. The resident was admitted with significant pain issues and had a physician order for Norco (hydrocodone-acetaminophen) to manage pain. Despite the order, the resident did not receive the prescribed Norco for at least 11 days, missing 11 doses, due to delays in obtaining the medication from the pharmacy and issues with obtaining the necessary prescription script. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as ibuprofen and acetaminophen were not effective. Nursing staff were aware that the Norco had not arrived and communicated this to the resident, but there was no documented escalation or effective resolution of the issue. Progress notes repeatedly indicated that the medication was "awaiting supply" or that the pharmacy had not received the script, yet there was no evidence of timely follow-up with the physician or pharmacy to resolve the delay. Interviews with nursing staff and facility leadership revealed a lack of awareness and communication regarding the ongoing medication issue. The DON and NHA were not aware of the missed doses until informed by an ombudsman. The physician and nurse practitioner involved were also not fully aware of the extent of the delay, and the physician did not review the medication administration record during a subsequent visit. Facility policy required providing care and services according to established practice guidelines, but this was not followed in ensuring the resident received the ordered pain medication.